Demand and Supply of a Product and Factors that Affect †Samples

Question: Talk about the Demand and Supply of a Product of your Choice and Factors that Affect the Demand and Supply Sides of the Market. Answer: This article dominatingly looks at the deferred hang in the economy in the United States as needs be of a diminishing in the oil business because of the declined oil cost and provoking liquidations. The observational conviction is that oil costs have dropped out and out through the range of the past some time, as communicated in this article. A basic activity of the monetary nuts and bolts of the laws of free market action by request and flexibly can be used to explain this rule. Request just as gracefully assumes a critical job in this article as the drop in the costs influences the interest because of a development along the interest bend, prompting another balance position being framed. The law of flexibly communicates that there is a positive causal connection between the amount of the great provided over a specific timeframe and its cost, ceteris paribus[1], consequently, the overall gracefully remains high. Simultaneously, it is found in the article that huge creators like Saudi Arabia alluding to no reducing age and the overall economy directing, anticipating that the market should remain in unrest until 2017 all through. With a development in the making of oil, the flexibly fabricates, therefore provoking a fall in the worth degrees of oil. This can be handily observed on the interest gracefully chart by a move or a development along the interest bend. An ascent in the gracefully in Fig.1 is noticeable by a development along the interest bend from A to B followed by a rightward move of the flexibly bend from S1 to S2. The move would influence the balance cost just as the balance amount, bringing about an expansion in the harmony amount and a fall in the balance cost. The hub of the outline have been named to show the cost just as the amount of the oil in barrels and bolts demonstrate the adjustment in the value which is found in Dollars along the Y hub. As appeared in Fig.1, in light of a development in the flexibly, an overflow would be made as the amount provided (Q2) is more noteworthy than the amount requested (Q1). Where the general gracefully is more prominent than the general interest, a creation surplus happens and besides makes the costs be balanced descending so as to adjust the excess that has been made. Meanwhile, all in all, if there is a huge responsiveness of amount requested, request is alluded to as being value versatile; if there is a little responsiveness, request is cost inelastic.[2] This applies for the sum gave as well. The solicitation, and moreover the flexibly of oil, is cost inelastic as oil is a fundamental extraordinary asset and no monetarily effective different alternatives to oil have been found at this point. This suggests in the short run, a climb in the expense of oil would provoke a practically zero fall in the sum mentioned and accommodated oil. By and large, an extended gracefully of oil would p rovoke an extension in the enthusiasm for oil eventually, bringing the expense just as the amount requested back to the balance, along these lines achieving the best results for the best improvement of the economy. As the cost level is set over the harmony amount (An), an oversupply-additionally knows as an overflow would create an exorbitant measure of the great or the administration to be delivered both in the short just as the since a long time ago run. As per the law of interest, there is a negative causal connection between the cost of a decent and its amount requested, ceteris paribus.[3] Over a time period, an excess would enable firms to diminish expenses and gracefully less, extending the interest for the product and adventures and from this time forward returning the balance forthright (A). In this way, the sum gave would lessen until the amount requested equivalents the amount provided, getting rid of the excess and therefore developing a market balance which is where the amount requested equivalents amount provided, and there is no inclination at the cost to change.[4] Besides, as communicated in the article, there has been a slight drop in oil costs from $100 a barrel in late 2014 to just around $30 per week back. This has prompted the drop not simply impacting the close by producers in the economy anyway the remote oil creators moreover. A fall in the expenses of oil would provoke an extension in the joblessness levels as the enthusiasm for the pros in the business would fall, inciting a mishap in the amount of occupations in the business. In any case, those used in ventures that rely upon oil as their imperativeness source would encounter a development in work in light of a fall in the expense of creation and in this manner an extension in the flexibly, thusly extending the general age. This would additionally prompt a progression of drawn-out and chaotic insolvencies, inciting a lower run of the mill typical cost for basic items for essential things for the partners which would, in this manner, lessen their pay. A lower age pay that before woul d, thusly, bring about an extended load on the pay of the economy impacting the associations and furthermore the individuals in the economy, prompting different results which would influence the economy all in all. With everything taken into account, to clarify the job of interest in an economy, the measure of a thing that people will buy depends on upon its expense. You're routinely anxious to buy less significantly a thing when costs rise and indeed a thing when costs fall. When in doubt, we find things all the more engaging at lower expenses, and we buy more at lower costs considering the way that our pay goes empower. Using this method of reasoning, we can fabricate a solicitation twist that shows the measure of a thing that will be mentioned at different expenses. Reference index: Tragakes, Ellie, Economics for the IB Diploma-Second Edition (Cambridge: Cambridge University Press, 2012) Staff, Investopedia. Oversupply. Investopedia. June 11, 2010. Gotten to May 10, 2016. https://www.investopedia.com/terms/o/oversupply.asp. Tragakes, Ellie. Financial aspects for the IB Diploma. Cambridge: Cambridge University Press, 2009., 26. Tragakes, Ellie. Financial aspects for the IB Diploma. Cambridge: Cambridge University Press, 2009., 22. Tragakes, 31.

Competitive Strategy for Pharmaceutical Patent -myassignmenthelp

Question: Examine about theCompetitive Strategy for Pharmaceutical Patent Analyst. Answer: Presentation Upper hand of an organization is alluded to the influence it has over its rivals which is created by offering better and more prominent worth. So as to create an upper hand, pioneers center around actualize business arrangements that depend on qualities of the undertaking. While actualizing business approaches for creating an upper hand, pioneers need to assess the earth in which the organization or its items/administrations tasks. Successful assessment of the earth helps the executives in making business strategies that give the organization an upper hand. This article will assess SWOT investigation, Porters Five Forces system and PESTLE examination dependent on pharmaceutical, the travel industry and farming industry individually. This exposition will concentrate on Wesfarmers Limited, Qantas Airways, and Australian Pharmaceuticals Industries. SWOT Analysis The SWOT examination is a helpful apparatus that helps with distinguishing qualities, shortcomings, openings, and dangers of a specific organization or its item/administration. The model was initially evolved during the 1960s, and it has stayed unaltered in the vital administration field (Culp et al., 2016). This model helps administrators in building up their business techniques by surveying distinctive outer and inner elements that influence hierarchical execution. The elements in an outer domain incorporate government enactment, social desire, evolving patterns, and rivalry. Interestingly, inward condition factors incorporate hierarchical culture, human asset capacities, adequacy of approaches and initiative ability (Roghanian, Ghorbani, and Alipour, 2018). The model is utilized by various administrative work force in an organization at different levels. For instance, the directorate and official officials use SWOT system while actualizing future business methodologies. Then again , low and medium level directors use SWOT examination while taking independent venture choices while performing every day undertakings. A case of Australian Pharmaceuticals Industries (API) is utilized so as to actualize SWOT investigation. The organization works in the pharmaceutical area, and it is engaged with assembling, dispersion and retailing of pharmaceutical, wellbeing and excellence items. Its qualities remember the biggest discount merchant of pharmaceuticals for Australia, offered a wide scope of administrations, numerous milestone items, specialty player in the over-the-counter market, and great generally speaking development rate (Almarsson, Peterson and Zaworotko, 2012). Its shortcomings incorporate Sigma takeover contentions, asserted bookkeeping inconsistencies, the industry is ruled by three key players, Sigma, Symbion Health and API and the organization may lose center from its principle items on the off chance that it branches into new markets. Its chances remember scope for advancement of individual consideration territory, stripping of pharmaceutical resources for concentrating on center abiliti es, and development in mindfulness about social insurance. Dangers remember changes for pharmaceuticals evaluating plan, exchange obstructions may hurt net revenues of the firm and rigid principles against clinical tests. Watchman Five Force Framework It is an important device planning to break down the prompt serious condition of an organization. It is an industry investigations system which considers explicit powers that decide rivalry in an opposition (The Economic Times, 2018). The impact of these five variables encourages financial potential and seriousness of a division. Ventures share same qualities and the five powers model helps with distinguishing speculation appeal, the effect of fundamental drivers and appraisal of the benefit capability of organizations. The powers incorporate the danger of passage, the danger of substitutes, the intensity of purchasers, the intensity of providers and the serious contention. The assessment of these five basic variables helps with summing up the most significant standards to consider for examining a particular industrys key drivers of accomplishment (Zhao et al., 2016). The top-level administrative staff utilizes this model while entering another division or propelling another item in the market. A case of Qantas Airways is utilized so as to actualize Porters five powers model. The enterprise works in movement and the travel industry, and it offers aircraft administrations to its clients. The organization additionally empowers its travelers to book the travel industry bundles straightforwardly from its sites, and it is third most visited the travel industry sites in Australia. The haggling intensity of purchasers in the business is high on the grounds that countless neighborhood and universal aircrafts work in the business and clients can undoubtedly switch between them without extra costs (Chen and Muzi, 2013). The bartering intensity of providers is high on the grounds that Boeing and Airbus are the essential airplane producer, and they can undoubtedly bring airplane costs up in the segment. The danger of substitutes is low since air travel is the fasters and more agreeable choice than its choices, for example, transport, train, and vehicle. The danger of new section is low er due to high beginning venture costs and exacting administrative prerequisites (Sarina and Wright, 2015). The competition among existing firms is generously high on the grounds that some ease aircrafts have entered the market which has decreased the benefits of Qantas. The contention has likewise expanded in view of merger and procurement in the business. PESTLE Analysis A PESTLE investigation helps organizations in breaking down six of the key outer elements that impact a business and choices taken by the administration. The outside components incorporate political, monetary, sociological, mechanical, lawful and natural. The model evaluates the potential effect of these components on a partnership. Along these lines, organizations can get ready deliberately for any future changes by monitoring the outer market which gives them an upper hand (Fozer et al., 2017). The model empowers associations to decide the present job and status of the organization corresponding to its rivals and gathered market data that helps the executives in making future improvement systems. The way toward gathering significant data that aids the advancement of business methodologies is called key review, and a PESTLE investigation helps the board in directing key review of the outside condition of the enterprise. This apparatus is utilized by senior level administrative work force to comprehend the present situation of the organization in the market and dependent on such data making future methodologies for supporting the development of the endeavor. A case of Wesfarmers Limited will be utilized for breaking down PESTLE investigation. The organization is a combination which works in various segments, for example, retailing, horticulture, coal mining, synthetic compounds, and others. This PESTLE investigation will concentrate on farming activities of Wesfarmers. Political steadiness and commitment of horticulture area to 3 percent of the countrys economy is valuable for the organization (National Farmers Federation, 2017). The steady economy of Australia adds to the development of agribusiness activities of Wesfarmers; be that as it may, the organization faces higher compensation costs than contrasted with different countries. The mindfulness with respect to new and wellbeing food items is developing, and clients want to purchase Australian developed items which are helpful for Wesfarmers since its agribusiness activities are arranged in Australia. The organization utilizes diverse present day advancements in its horticulture acti vities, for instance, it has propelled Decipher which is Google Earth Engine based business cultivating administration which uses satellite pictures, preparing power and geospatial information for giving inside and out vegetation examination (Thompson, 2017). The partnership agrees to Australian Agriculture approaches so as to guarantee that its food items are not perilous for individuals, and they are made without hurtful manures. The organization has likewise actualized continuing horticulture program in which it has teamed up with Carbon Trust Company which help it in decreasing its carbon emanations (Wesfarmers, 2018). All in all, various instances of organizations from businesses, for example, pharmaceuticals, the travel industry, and agribusiness are talked about for understanding the job of methodology improvement instruments, for example, PESTLE examination, Porters five powers structure and SWOT investigation. Each instrument empowers the board to assess outer, inside or the two elements which impact their business and the data gathered by the devices permit the administration to make vital approaches. Viable utilization of these instruments helps organizations in getting present and future factors that influence their business and empower them to make vital strategies for supporting their future development. References Almarsson, ., Peterson, M.L. also, Zaworotko, M. (2012) The a to z of pharmaceutical cocrystals: a time of quick moving new science and patents.Pharmaceutical patent analyst,1(3), pp.313-327. Chen, Z.H. also, Muzi, H.E. (2013) A Casebased Analytical Study on the Strategic Evaluation of Common Equity Performance of SIA in a Global Organic Environment.Journal of Contemporary Management,1(1). Culp III, K., Eastwood, C., Turner, S., Goodman, M. also, Ricketts, K.G. (2016) Using a SWOT Analysis: Taking a Look at Your Organization [2016]. Network and Economic Development Publications, 3, p. 1. Fozer, D., Sziraky, F.Z., Racz, L., Nagy, T., Tarjani, A.J., Toth, A.J., Haaz, E., Benko, T. also, Mizsey, P. (2017) Life cycle, PESTLE and Multi-Criteria Decision Analysis of CCS process alternatives.Journal of Cleaner Production,147, pp.75-85. National Farmers Federation. (2017) Farm Facts. [Online] National Farmers Federation. Accessible at: https://www.nff.org.au/ranch facts.html [Accessed on 17 April 2018]. Roghanian, E., Ghorbani, B. also, Alipour, M. (2018) Applicati

Easy Essay Topics to Write About

Easy Essay Topics to Write AboutEasy essay topics to write about include religion, social studies, history, geography, science, world geography, government, economics, law, psychology, language, music, and more. As you begin your research, it is likely that you will find that some topics are easier than others. For example, some subjects are easier to write about because of the real life experience of the writer. While other topics are easier to write about because they do not require a great deal of skill on the part of the writer.The easiest essay topics to write about are religious subjects. These topics are the easiest for a wide variety of reasons. The first reason is that religion is such a personal and intimate subject. Religion gives us a feeling of security and helps us cope with situations that we might otherwise be faced with.In addition, easy essay topics to write about include a variety of stories related to religion. Stories such as the story of St. Jerome's conversion to Christianity or the story of Christ. Stories such as these help us to understand the lives of those who follow a religion or celebrate a religious holiday.One of the easiest topics to write about would be a simple paragraph describing a typical day in a typical family. You may be able to include a short biography of the family, or perhaps a short anecdote about each member of the family. The most important thing is that you try to give the reader a sense of what it is like to live the life of that family.While easy essay topics to write about religion might seem to be a great idea, there are many writers who feel it would be difficult to write a paper. When you think about it, why would you need to write a paper about something that you can understand already? You might say that you would like to write a paper about the family but find it impossible to write about your own family? Perhaps this would be true for the past or the present and possibly not for the future.Even though i t may seem impossible to write about anything that is out of the ordinary, the easiest essay topics to write about may be that of an essay. If you can find an essay topic that is related to the topic of your choice, then you have made it. In fact, with online writing, there are a variety of free online essay topics to write about.If you have a difficult time figuring out what topic to choose, then you should look at some writing resources. These resources provide you with helpful tips and suggestions on how to write a successful essay.It can be very difficult to write an essay and you may even be the type of person who has difficulty writing at all. If you find that you do not have the ability to write, or that it takes too much time to write, then you should consider online writing. This way, you can learn how to write an essay without having to sit in front of a computer for hours on end.

A Beautiful Friendship Adolf Hitler and Josef Stalin

The 60th anniversary of one of the most fateful events in world history went unremarked this week. On Aug. 23, 1939 Adolf Hitler and Josef Stalin agreed to what became known as the Nazi-Soviet nonaggression pact. With that, Stalin made World War II possible. Assured that he was protected from Soviet counter-aggression in the East, Hitler invaded Poland a week later, Sept. 1. The signal that something was up between the two totalitarian powers had come some four months earlier but European chancelleries overlooked it. For on May 3, 1939 came the startling news that the Soviet Foreign Minister Maxim Litvinov had resigned at his own request. Litvinov, of Jewish origin and strongly anti-Nazi, had been replaced by Vyacheslav Molotov. His†¦show more content†¦Thus the anti-Nazi parties were rebuffed, on Stalins orders, when in 1932 they appealed to the German Communist Party to form a united front against the Nazis. In other words, Stalin wanted the Nazis in power because in a few years, so he believed, they would be ousted and Germany would eventually fall into his lap. Revisionist historians have been trying to sell a fairy-tale that Communist Party members wanted nothing but good for the working-class. Their demurrer: only a handful were spies for Stalin. But these mainstream historians ignore the ignominious role the Communist Party played during those crucial months of the Nazi-Soviet Pact when France fell in 1940 and Britain stood alone. French Communist Party members sent anonymous letters to soldiers on the Maginot Line detailing the fictitious amours of supposedly adulterous wives. In America the communists fought conscription; communist-controlled CIO unions called strikes against aircraft factories to prevent shipment to France or England of warplanes they had paid for. The Daily Worker called it the Second Imperialist War, the Soviet dismemberment of Poland an action taken in the cause of world peace. Earl Browder, Communist Party leader, called FDR an unlimited military dictator who had adopted the techniques of Adolf Hitler. Congress wa s called the Hitler Reichstag. And then overnight the Second Imperialist War became a Peoples War, when on June 22, 1941, Hitler invaded the USSR -Show MoreRelatedOne Significant Change That Has Occurred in the World Between 1900 and 2005. Explain the Impact This Change Has Made on Our Lives and Why It Is an Important Change.163893 Words   |  656 Pagescollectivist over the religious, the commercial, and the individualist. They annihilated cathedrals, abbeys, fortifications, and ceremonial gates and towers and did their utmost to erect idols to themselves and their creed (1995, 3–4). In 1928, as Stalin introduced the first of his five-year plans for Russian economic development, primarily through industrialization, and began to do away with private farms by collectivizing agriculture in the 1930s, rural people fled the countryside and migrated

Shakespeare and Kingship - 1614 Words

In writing his history plays, Shakespeare was actually commenting on what he thought about the notion of kingship. Through his plays, he questions the divine right of kings, which the kings and the aristocracy used heavily in their favour to win the peoples love. In Macbeth, King Richard II and King Henry IV part 1, Shakespeare shows us his opinion of kingship in general. Although the plays are written about individual kings, I think that Shakespeare used the plays as an opportunity to voice his opinion on kings and kingship in general. This was assisted by the fact that he was not prohibited by the true events, because it is well known that all of Shakespeares plays were written purely for entertainment value, not as a historical†¦show more content†¦However, Macbeth has been tricked by the witches because MacDuff is able to kill him because he was From his mothers womb | Untimely rippd Because of the witches prophecies, Macbeth thought that he was assured the power of king, knowing that the only way he could be brought down was when Great Birnam wood [comes to] to high Dunsinane hill , something Macbeth was sure could not ever happen. He was also told that none of woman born | Shall harm Macbeth , and Macbeth did not think that it was possible that anyone could not have been born from a woman. Macbeth was told all these things by apparitions which the witches had shown him, and he believed them, probably because it was what he wanted to believe - that he could not be harmed by anyone, that his demise would never happen. Macbeth was so sure that he could not be defeated that he totally disregarded the people, killing people at a whim, and he did not ever think that they would go against him and eventually overthrow and kill him. In Richard II, Richard totally ignores the common people, to an even larger extent than Macbeth did. The people came to hate Richard because he paid no attention at all to them, did nothing to support them and then bankrupted the entire country by spending money on his favourites, who were already rich aristocrats. The people resented this, and I think that Richards total disregard for the common people allowed Bolingbroke to step inShow MoreRelated Shakespeare And Kingship Essay1595 Words   |  7 PagesShakespeare And Kingship In writing his history plays, Shakespeare was actually commenting on what he thought about the notion of kingship. Through his plays, he questions the divine right of kings, which the kings and the aristocracy used heavily in their favour to win the peoples love. In Macbeth, King Richard II and King Henry IV part 1, Shakespeare shows us his opinion of kingship in general. Although the plays are written about individual kings, I think that Shakespeare used the playsRead MoreShakespeare - His View on Kingship1600 Words   |  7 PagesShakespeares ideas towards kingship can be seen throughout the play. He shows that a king should be chosen by divine right and shows the attributes of what a good king should be. The play ‘Macbeth is set in medieval Scotland at the fictional time of King Duncan. Scotland is currently at war with the Norwegians when news of their victory comes through, with thanks to the two leaders of the army Macbeth and Banquo. On their travel home Macbeth and Banquo stumble upon some old hags, and they predictRead MoreEssay on Shakespeare, Kingship, and the Chain of Being in Macbeth814 Words   |  4 PagesShakespeare, Kingship, and the Chain of Being in Macbeth Shakespeares play Macbeth is largely based upon the theme of kingship. Macbeth was written for James the 1st, who would have been interested in kingship and believed in the chain of being and the divine right of kings. The chain of being is the belief that everything is connected like a chain, and is affected by anything above it. God was believed to be at the top of the chain, and the King was believedRead MoreWilliam Shakespeare s Richard II1543 Words   |  7 PagesSamantha Van Dine Richard Spacek ENGL 3250 September 24, 2015 Richard II, William Shakespeare Richard II is a play written by William Shakespeare in the closing stages of the 16th Century. It is based on Richard II and his scheme of taking the throne of England. Richard II is a carefully balanced play, characterized by precise and formal arrangements of characters and actions. This balance is enhanced by various parallel incidents which are included in the themes, plots, and the nature of theRead MoreTheme Of Kingship In Macbeth938 Words   |  4 PagesShakespeare employs a similar technique under the rule of James I through the prevalent theme of kingship throughout Macbeth, demonstrating the tyranny of the fictional Scottish King as the antithesis of the English monarch. 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Dollimore believes King Lear is about power, poverty and inheritance. Shakespeare focusesRead MoreMacbeth Character Analysis Essay762 Words   |  4 Pagesexposed in his words in act 4 scene 1: â€Å"Time, thou anticipatest my dread exploits: / The flighty purpose never is oertook / Unless the deed go with it; from this moment / The very firstlings of my heart shall be / The firstlings of my hand.† (Shakespeare 4.1.162-166). His evil character, which changed after becoming a king, matches with his understanding of kingly rule – he believes that king can do anything even though it is a dread exploit. Even though Macbeth becomes a king of Scotland, he feelsRead MoreHenry’s Use of Language in Act IV, Scene 1 of William Shakespeares Henry V1298 Words   |  6 PagesHenry to become introspective, analysing himself as a leader and conveying to the audience his complex positions during this troubling time through a range of linguistic features used in the soliloquy. Throughout the soliloquy Shakespeare uses repetition to emphasise the demands of Henry’s kingly responsibilities. Through his conflicting impulses he repeats words to make sense of his troubling emotions. The repetition of the familiar possessive pronoun ‘our’ can be found

Marijuana Legalization - 1212 Words

Marijuana Legalization COMP 1500 April 20th, 2009 Word Count: 807 Outline I. Introduction Thesis Statement: Although America is the land of the free you do not really have too many free choices you can make. Americans should have the right to choose whether or not marijuana should be legal. II. Background III. The tax benefits that can be created A. If legalized they can tax it how ever much they want B. Can be regulated IV. Drug enforcement money can be diverted. A. Can help other needy departments that lack money. B. Keep the court system and jails less full for real criminals V. It’s no more harmful then alcohol or tobacco A. Must use it in moderation. B. If abused it can cause†¦show more content†¦Therefore; giving the government more money to spend on different governmental agencies that are in need of the extra cash flow. Not only would it give us more money for other departments but it would also keep are court systems less crowded and jails freer. â€Å"Many consider the War on Drugs an expensive failure. Resources for DEA, FBI, and border security are only the tip of the iceberg. You must add in the cost of police officers, judges, public defenders, prosecutors, juries, court reporters, prison guards, and so on. Legalization of marijuana would free up those people to concentrate on more important things like terrorism, harder drugs, rape, murder, and so on† (Should marijuana be legalized). Marijuana is proven not to be more harmful then tobacco, or alcohol if used with self-control. â€Å"Most doctors would agree that its not very harmful if used in moderation. Its only when you abuse the drug that problems start to occur† (Should marijuana be legalized). But isn’t that true if you abuse anything problems start to occur? For example if alcohol, coffee, or food just to name a few are abused you could develop serious health conditions. But would you want the government to tell you how much food you could eat or how much alcohol you can consume when you go out? People should be able to make their own dictions when it comes to their health. So what makes marijuana anyShow MoreRelatedThe Risk Of Legalization Of Marijuana Essay722 Words   |  3 PagesThe risk of Legalization of Marijuana Marijuana, as we know, is a kind of drug. According to Thompson (2015), marijuana is not only one kind of drug, but also can be used as a medicinal material. The reason it can be a medicinal substance is that marijuana has a curative affect of relieving pain. 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Interesting accumulating evidence show that the significant negative impact of this drug outweighs the positive effects. However, the medical benefits of the drug seem on the process of chemical compounds as compared to the drug itself. Medical debates show that chemical compound in marijuana are the problem as compared to the plant. The said chemical compound affects the mental and physical health of the personsRead MoreEssay on Speech on Legalization of Marijuana in Brazil870 Words   |  4 PagesSpeech on Legalization of Marijuana in Brazil Good morning class mates. Today I am going to discuss the legalization of marijuana in Brazil. I strongly believe marijuana should be legalized. I am not here to encourage anyone to use or not use marijuana. Yet I do believe that many current problems may and can be solved by its legalization. Marijuana is the most popular drug in Brazil after tobacco and alcohol. Discrimination is the reason why marijuana has still

The Strategic Role of UAE Space Agency in Promoting National Security

Question: Discuss about the Strategic Role of UAE Space Agency in Promoting National Security - An Insight to The Future. Answer: Overview The United Arab Space Agency was established in the year 2014 under the supervision and funding of UAE government. The main purpose of the agency is to provide the world class sustainable development and work in collaboration with various types of research and development agency. The strategic goal of the agency is to develop the world class space development program that can help in the purpose of promoting the scientific research work (Marpu 2017). One of the major part of the strategic program is the development of the space program is the development of the national security protocol by the UAE armed force. This is achieved by the mode of better level of communication using the different forms of satellite. The space program is also planning to implement the strategic command program for the control of the satellites that will help in the purpose of the better level of communication. The access of the space program is highly essential for the development of the national security as it can help in the process of tracking about all types of external threats that can come from illegal activities or terrorism from other nations. The space agency also plays significant role in the part of the predicting the weather and all types of natural disasters. In the given context, the current research work will aim to highlight upon the strategic role that is played by the UAE space agency in dealing and promoting with the matters related to that of national security. The main area of the research will highlight the future role and strategy of the space agency that will be implicated to advance the level of national security. Research Questions Following are the key research questions To explore the role of space agency in dealing with the matters related with that of national security. To explore the role of space agency in development of future strategies related with that of national security of UAE. To explore the role of partnership of the UAE space agency in the matters related with that of the national security. The objectives that can be drawn from the research questions are as follows: Critical examination of the strategy that are developed by the UAE space agency that help to promote the national security. Determination of the future strategies that are developed by the UAE space agency in the matters of future of the national security. Examination of the role of partnership by the UAE space agency for the development of the national security. Relevant Literature Strategy Management for Internal Security Thestrategic management is related with the path that are being followed within an organization or achieve the organizational goals. According to Alnaser et al. (2017), every strategy that are implemented need to carefully analyze the external environment to ensure maximum benefit can be achieved. It is also essential for the organization to properly develop the framework of the strategy that will help them to develop a proper path for the process of implementation. As mentioned by Jang, (2016), one of the main characteristics of an effective strategy related to that of the internal security is to collect relevant data and analyze the external threats. Themanagement and governance is the primary components of the strategic framework that helps to deal with matters of security. This is needed to deal with most of the internal and external forms of risks. It is also essential to make use of the risks assessment tools that will depend upon the nature of the external threats and risks that are involved within the position. As it is possible to deal with the major components of the threats and identify the same, in the following steps, it is essential to implement standard policy. This will aim to deal with the neutralize all forms of threats by following the security protocols. The policies will also help in the purpose of the dealing with the information and the procedures that are to be followed for getting the proper information. It is also essential to socialize the procedures that are related with that of the security protocols (Meraj et al. 2016). The development of the compliance is also one of the major components of the strategy framework. The goal of this procedure is to develop the cultural awareness within an organization or agency that can help to define all types of policies that are previously implicated. The security awareness program is also another major component of that is needed to justify all forms of policy that are previously implicated. The security assurance is the following steps for the strategy development program that is needed to provide a better forms of road maps within the organization. It is also important to deal with risk exposure and all types of environmental changes that has the potential to identify all forms of threats. It is also essential to deal with all types of threats that is evident for the future. In the following step, it is necessary to review all types of incidents that has the potential to compromise upon the internal security of a nation. These may include review of the terroris m and other forms of violent activities. It is also important to generate some rapid response activities in the context of the situation analysis. The basis of quick response can also be generated from all types of actions that has the potential to deal with major activities related with security threats. The importance of the performance metric is the final components of the strategic plan. This is also important to monitor the effectiveness of the theories that are being implemented as a part of the security measures (Al-Khouri et al. 2014). UAE Space Agency One of the major intention of the space program that has been initiated by the government agency in UAE is to establish their power within the world forums. The major part of the project was launched in July 2014 with the public announcement of the Hope Mars Mission (Benmamoun et al. 2016). This makes UAE the only nation in the Arabian region, who has been able to establish a space agency in the international forum. The geographical location of the nation is also ideally suited for the future prospect of the space program. The location in the southeastern edge of the Persian Gulf will help to deal with all major types of launch programs that are associated with that of the satellites. There are also the expansive deserts and several miles of coast lines that provide with the opportunity of safe rocket launch. There is also the advantage of the position near the equators that help in them to easily position the satellites in accordance with the spin of the Earth. This means that there is less requirement of the upper push that is needed in case of the rocket launch. This will help in the matters of less fuel expense (Young 2017). The financing of the space program is done from the government and private agencies, who has provided near about $5.2 billion (Al-Khouri et al. 2014). The chairperson of Al Masakari Holding, Sheikha Al Maskari is able to provide encouragement to the work of the space agency. She is able to make use of her communication skills in the department of marketing and is able to use the opportunity to deal with the space program. By the year 2020, the agency is planning to send human pilot within the space development program. The main of the program is develop sustainability within the space program that is needed to send men in the space program. By the end quarter of 2018 the government is planning to initiate the space development program by giving training to the astronauts. This will then help the space program to decide for the candidates for sending within the outer space. The agency will also set up partnership with the Russian International Space Station (Leloglu and Kocaoglan 2008 ). Promotion of National Security Currently the internal security of UAE is facing huge challenges due to the increased threats of terrorism. From the very origin of the nation the small sized population of the region seems to be one of the biggest challenges for the government. The increased number of cases of the mining activities also seems to be major cause of concerns for the security within the nations (Jang 2016). The planning for the security seems to be one of the major challenges that was achieved by nurturing of the military alliances within the section of the Gulf Cooperation Alliance. There are also has been increased number of threats due the civil war in the neighboring nation of Syria. There is also high level of threats from the Islamic State terrorist activities in the nation of Iran. Meraj et al. (2016), have mentioned about the fact the space sector activity of UAE has been developed with the growing demand of the security issues. The policy within the space program is to develop the economy of the nation and also to bring about diversification in the security programs that will help to deal with all types of threats from the external sources. The security policy will combine with that of the space development program that will be the major support for all types of industries with the economy of UAE (Al-Bolushi 2016). This will help in the path of sustainable development. The space program is also believed to introduce the technological elements within the matters of security. The military group can also get the help the proper instructions that is needed to deal with the national security. It is important for the space agency to implement the policy for the security with the help of proper strategy (Murphy 2006). Methodology This section of the proposal will provide the details about the methods and research design that will be used by the investigator Research Philosophy This is the form of believe that is followed in the matters of collecting data and analyzing the same for making the result of the research. There is the positivism form of research philosophy, where the reality is believed to be stable in the forms of dealing with the matter related with that of the research subject. For the research work of identifying the strategic role of UAE Space Agency in Promoting National Security, it will be effective to use the interpretivism research philosophy. This will help the researchers to make various types of interpretation that is related with that of the subject of the research (Flick 2015). Research Design There are three types of research designs that can be used by the researchers to deal with relevant matters. In case of descriptive research design, the investigators will make use of the detailed data that are available for the research work (Vaioleti 2016). While in case of the exploratory research design, the investigators will deploy the previously used research articles and information for the current work of investigation. This will be used in the current research work to make interpretation about the future security strategies that will be implicated by the UAE government in assistance with that of the space agency program. There is also the descriptive type of research design that will be used by the current investigators. This will help in the matters related to collecting important information about the security protocols. Data Collection Methods There are two types of Data Collection method that are primarily used in all research works. In primary mode of Data Collection the investigators collect the information directly from the sample size in the form of interview or survey. With the help of primary data it is possible to get the latest possible information about the research subject. On the other hand, in case of secondary data information are collected from secondary sources which includes previous investigation work of the same subject (Panneerselvam 2014). For the given research work, for investigating the purpose of space agency program in national security of UAE, both primary and secondary form of data will be used. The primary data will be collected from the interview of the government officials of UAE. Sampling size There are two types of sampling methods that are deployed in a research work. In random or probability sampling method, the researchers select the sample size on random basis. While in case of non-probability sampling, the size of the sample is predetermined. In this case, the researchers focus only upon the predetermined sample size and collect relevant information (Tarone et al. 2013). For the given research work, the researchers will have Predetermined sample size, where interview will be conducted upon 10 government officials of the UAE space agency. Research Strategy The strategy of the research is the methodology and Framework that are being followed by the investigators in order to identify the issue within the research topic. The strategy of the research helps to address the Research question in a systematic way. The current research work will aim to implement effective research strategy, which will be in a form of quantitative and qualitative data analysis. This will help the investigators to highlight upon all the background information related to the space program and national security of UAE. This will also help to ensure that all the statistical information are properly valuated before making proper conclusion. Expected Outcomes The major benefit of the research work will be upon the fact that it will be able to highlight importance of internal security protocols that will be implemented by the UAE government. It will also help to highlight upon the importance of space program that are initiated by the UAE government. There also has been major concern about the huge expenditure that are spent by the UAE government on the space program. As the current research work will be able to highlight upon the importance of internal security and use of Technology using the latest form of Satellite program, it will be possible for the general public to understand the importance of the same. This will also help in the purpose of raising funds for the space programme initiated by the UAE government. As the investigators will analyse the background information of the space program, it will also be possible to evaluate the success of the program in terms of improving the level of internal security. It will also be there for possible to highlight up on all forms of threads that are encountered by UAE from external sources. Timescale The total time for the research is of 36 months Research Stages Month 1-4 Month 5-10 Month 11-15 Month 16-22 Month 23-30 Month 31-33 Month 34-36 Research Topic Selection Data collection from secondary sources Creating Framework Literature review Panning of the research method Selection of the Appropriate Research Strategies Primary data collection from sources Analysis Interpretation of Collected data Findings of the Data Conclusion of the Study Formation of Draft Submission of Final Work Gnatt Chart (Timeline) References Al-Bolushi, M., 2016. The effect of Omani-Iranian relations on the security of the Gulf Cooperation Council countries after the Arab Spring. Contemporary Arab Affairs, 9(3), pp.383-399. Al-Khouri, A.M., Farmer, M. and Qadri, J., 2014. A government framework to address identity, trust and security in egovernment: The Case of UAE IdentityManagement Infrastructure. European Scientific Journal, ESJ, 10(10). Alnaser, A.S., Abdel-Naby, S., Syed, R., Sakhi, S., Salamin, Y., Egilmez, M., El-Khatib, S., Hamdan, N., Guessoum, N. and Majeed, T., 2017, July. Frontiers in Theoretical and Applied Physics/UAE 2017 (FTAPS 2017). In Journal of Physics: Conference Series (Vol. 869, No. 1, p. 011001). IOP Publishing. Benmamoun, M., Sobh, R., Singh, N. and Moura, F.T., 2016. Gulf Arab E?Business Environment: Localization Strategy Insights. Thunderbird International Business Review, 58(5), pp.439-452. Flick, U., 2015. Introducing research methodology: A beginner's guide to doing a research project. Sage. Jang, J.H., 2016. Charting a path toward a sustainable ROK space program (Doctoral dissertation, Monterey, California: Naval Postgraduate School). Leloglu, U.M. and Kocaoglan, E., 2008. Establishing space industry in developing countries: Opportunities and difficulties. Advances in Space Research, 42(11), pp.1879-1886. Marpu, P.R., 2017. The IEEE United Arab Emirates Section Chapter Is Gearing Up to Support the National Space Program [Chapters]. IEEE Geoscience and Remote Sensing Magazine, 5(1), pp.74-75. Meraj, M.A., Fernandes, C.J. and Ross, K.J., 2016. Applying marketing mix constructs in higher education: the case of an MBA program in the UAE. International Journal of Business and Globalisation, 16(2), pp.149-170. Murphy, E.C., 2006. Agency and space: The political impact of information technologies in the Gulf Arab states. Third World Quarterly, 27(6), pp.1059-1083. Panneerselvam, R., 2014. Research methodology. PHI Learning Pvt. Ltd.. Tarone, E.E., Gass, S.M. and Cohen, A.D. eds., 2013. Research methodology in second-language acquisition. Routledge. Vaioleti, T.M., 2016. Talanoa research methodology: A developing position on Pacific research. Waikato Journal of Education, 12(1). Young, K.E., 2017. A New Politics of GCC Economic Statecraft: The Case of UAE Aid and Financial Intervention in Egypt. Journal of Arabian Studies, 7(1), pp.113-136.

I was born Hispanic free essay sample

Describe any experience of cultural difference, positive or negative, you have had or observed. What did you learn from it? â€Å"My girlfriend†¦you know the tall brunette, well she swore he was just a friend†¦ but when†¦Ã¢â‚¬  â€Å"Be quiet, Matt. I’m trying to teach.† Quivering with impatience, the words had absolutely no effect. â€Å"No! Hold on†¦I’m not finished yet.† Returning to his tragic love story, Matt faced me and the rest of the table, his loyal listeners. Yet again the teacher interrupts. â€Å"Matt do we have a problem?† It was more of a threatening command than a concerned questioned. Annoyed, he replies, â€Å"Yeah we do. You won’t let me finish.† â€Å"Come see me after school.† There wasn’t a day when the teacher wasn’t disrespected, talked back to, and simply ignored. This was expected of the Hispanic students; the lack of respect for education, the expectation that the y wouldn’t amount to much in school. We will write a custom essay sample on I was born Hispanic or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page But in Sophomore English those degraded values and flimsy ideas towards education and its impact was almost every kid’s mindset. Each student contributed graying attitudes and negligence that weaved a unique environment. A class culture that impacted me as much as my Hispanic culture did concerning what role education would play in my life. I never was exposed to people who valued education. Of course, I saw Caucasian kids who planned to go to college, but they werewell, they didn’t have an accent. They didn’t have immigrant parents who depending on me for translating. They weren’t expected to be pregnant at sixteen or jumped into a gang. None of it. They had parents who spoke English fluently and who paid them for their grades. They were expected to attend college. They were expected to fulfill the American Dream. Yet, in sophomore English, it didn’t really matter what race, background you were. Everyone there hated English. Despite this common g round, I stayed close to mis amigas. Within my comfort zone, I watched the blond girl sitting next to me bring vodka, usually on Mondays because she was still hung-over from the weekend. I wondered if I should say anything when I saw the homegurl toss marijuana out the class room window to the homeboy waiting outside. Education meant nothing to them at all. Despite being exposed to this, I didn’t perfectly assimilate like the ten other failing students did, but it affected what goals I had. I struggled even seeing myself at community college. At the end of the year, the teacher advised me to take AP Language and Composition as a junior. She also offered it to two of my friends. We agreed. Liars! My friends had dropped the class. Walking into AP English, I felt highlighted in that room. Further into that period, just the way these students talked and acted was already intimidatingly different from last year. They participated in class discussions. They did homework. They frett ed about their grades. Most of them had taken Honors Sophomore English, the one where there weren’t hung-over students bringing vodka. They practice fierce academic vocabulary. Last year they just cussed hella. Isolated both ethnically and intellectually, I wanted to drop the class but stuck it out. This scholarly culture valued education, despite their financial or ethnic background, respected education as their sacred road to rewarding future. During group discussions, I found out that my different perspective as a Hispanic student could also contribute ideas or values or unearth details. Seeing fellow Hispanic students focus academically and succeed in an AP class culture helped me assimilate into obtaining an AP mindset where education is in the limelight. In my Hispanic peers, I watched unfolding success when society foretold failure. I was born Hispanic, but I wasn’t born into a failing stereotype. I embrace my roots, my different yet enlightening perspective, b ut I refuse to tolerate any limitations. I will guard my education, planting it in promising academic soil, an environment rich and diverse where I will be able to grow as I did in my AP Language and Literature class

Petición de asilo en EE.UU. y permiso de trabajo

Peticià ³n de asilo en EE.UU. y permiso de trabajo En Estados Unidos, el permiso de trabajo a los solicitantes de asilo, como regla general, no se concede durante la tramitacià ³n de la solicitud, aunque es posible una excepcià ³n a esta norma. Adems, si el asilo se aprueba ya se puede trabajar inmediatamente y no es necesario solicitarlo, aunque sà ­ es conveniente tener un documento para probar ese derecho ante los empresarios. En este artà ­culo adems de explicar la relacià ³n entre asilo y trabajo se informa sobre las nuevas directrices sobre solicitud de asilo y se recuerdan las principales obligaciones y derechos de las personas a quienes se les concede la solicitud y tienen, por tanto, calidad de asilados. Puntos clave: Asilo y permiso de trabajo en EE.UU. Regla general: Mientras se tramita la solicitud de asilo no hay derecho a un permiso de trabajo.Excepcià ³n a la regla: Puede solicitarse el permiso de trabajo si desde la presentacià ³n de la solicitud de asilo han pasado ms de 150 dà ­as, excluyendo los dà ­as de stop the watch y todavà ­a no hay resolucià ³n.  ¿Se puede solicitar un permiso de trabajo cuando se est tramitando una peticià ³n de asilo? La regla general es que el solicitante de asilo  no tiene derecho a trabajar legalmente en Estados Unidos. Sin embargo, si se cumplen al mismo tiempo las siguientes dos circunstancias se puede aplicar por un permiso de trabajo, conocido en inglà ©s como EAD: Cuando han transcurrido 150 dà ­as desde la fecha que se ha presentado la aplicacià ³n completa de asilo ante el USCIS o ante una corte de inmigracià ³n.Todavà ­a el oficial de asilo o el juez de inmigracià ³n no se han pronunciado sobre el caso.   Sin embargo, hay que tener en cuenta que ese transcurrir de dà ­as puede ser detenido por las autoridades migratorias siempre y cuando sea por causas atribuibles al solicitante. Es lo que se conoce como parar el reloj (stop the watch, en inglà ©s). Esta parada en el cà ³mputo de dà ­as puede deberse a mà ºltiples  razones como por ejemplo que el solicitante pida ms tiempo para obtener documentacià ³n,para buscar abogado, que no se presente a una cita, o renuncia vista rpida (expedited hearing) en determinadas circunstancias. Adems, el reloj se para una vez que el juez ha sentenciado negando el asilo. Si hay apelacià ³n, mientras dura à ©sta no se puede aplicar para permiso de trabajo. La decisià ³n de parar el reloj le corresponde en exclusiva a la administracià ³n. En la prctica esto significa que puede ser muy difà ­cil que se computen los 150 dà ­as y, por lo tanto, que se obtenga un permiso de trabajo. Adems, una vez que se para el reloj es difà ­cil volver a poner en marcha. Si no se tiene claro cuntos dà ­as han sido computados, se puede verificar llamando al telà ©fono automatizado de las Cortes de Inmigracià ³n marcando al 1-800-898-7180. En todo caso lo que hay que entender es que no se tiene derecho a un permiso de trabajo por el simple hecho de que hayan transcurridos 150 dà ­as desde que se presentà ³ la solicitud de asilo. No obstante, si reà ºne las circunstancias para solicitar el permiso de trabajo, entonces se puede aplicar rellenando la planilla I-765 prestando especial atencià ³n a la casilla nà ºmero 16. Adems, hay que tener en cuenta que el EAD no se aprobar por al menos 30 dà ­as. Con lo que la suma de los 150 ms los 30 hace que tenga que transcurrir un mà ­nimo de 180 desde la presentacià ³n de la aplicacià ³n. Adems, en algunos estados  se considera PRUCOL a los solicitantes de asilo y, a consecuencia de ello, podrà ­an tener acceso a algunos beneficios sociales. El permiso de trabajo con solicitud de asilo aprobada Lo cierto es que se puede trabajar desde ya, sin necesidad de ms documentos. No obstante, por cuestiones prcticas los asilados prefieren contar con un permiso de trabajo para poder probarle a un empleador que se puede trabajar legalmente en Estados Unidos. Otra razà ³n es para tener un I.D. emitido por las autoridades americanas, que facilita muchas gestiones de todo tipo. Si no les ha llegado uno con la aprobacià ³n, pueden optar por cualquiera de las opciones siguientes: Si el asilo ha sido concedido por un juez: solicitarlo gratuitamente rellenando la planilla I-765 y adjuntar la orden judicial en la que se reconoce el estatus de refugiado. Otra opcià ³n es hacer una cita para visitar unas oficinas del USCIS a travà ©s del servicio de InfoPass. Llevar el dà ­a seà ±alado la orden judicial. Adems, si el asilo ha sido concedido por el USCIS: contactar con la oficina que le ha concedido el asilo y pedirlo. El oficial de llevà ³ el caso procesa automticamente esta peticià ³n y se recibir en breve. Una vez que se tiene el permiso de trabajo se puede buscar empleo. Lo ms comà ºn es encontrarlo a travà ©s de familiares y amigos pero tambià ©n se puede recurrir a grandes bases de datos de ofertas de trabajo. Otros beneficios una vez que el asilo ha sido concedido Una vez que la solicitud de asilo es aprobada, el asilado puede disfrutar de ms beneficio adems del derecho a trabajar legalmente en Estados Unidos. Los principales son los siguientes: Se puede solicitar un Nà ºmero del Seguro Social.Si se necesita ayuda econà ³mica, mà ©dica, para aprender inglà ©s o para informarse de cà ³mo conseguir un trabajo contactar con la Oficina del Asentamiento de Refugiados (ORR, por sus siglas en inglà ©s) o marcar al 1-800-354-0365. Allà ­ orientarn a quà © clase de beneficios puede optar.Puede solicitarse la condicià ³n de asilados derivados para su esposo, esposa o hijos solteros menores de 21 aà ±os. Todos ellos tienen que haber sido nombrados en la peticià ³n original de asilo.Se puede solicitar permiso para viajar fuera de Estados Unidos. Se trata de un Documento de Viaje de Refugiado y para obtenerlo hay que rellenar la planilla I-131 antes de viajar fuera del paà ­s. Tiene validez por un aà ±o.Despuà ©s de un aà ±o es posible solicitar un permiso de residencia o green card mediante un ajuste de estatus. La planilla a rellenar es la I-485. El cà ³mputo del aà ±o se inicia a partir de la fecha en la que el asilo es aprobado. Obligaciones principales de los asilados Cuando se le aprueba a un extranjero su solicitud de asilo, à ©ste contrae una serie de obligaciones, destacando: Obligacià ³n de notificar al Servicio de Inmigracià ³n y Ciudadanà ­a (USCIS, por sus siglas en inglà ©s) todos los cambios de domicilio permanentes en los diez dà ­as siguientes a producirse la mudanza. En el caso de que el asilado es  varà ³n y tenga una edad comprendida entre los 18 y los 26 aà ±os est obligado a registrarse para los Servicios Selectivos. Si no lo hace puede que en el futuro se le nieguen beneficios migratorios. Por ejemplo, los asilados con el paso del tiempo pueden convertirse en residentes permanentes y despuà ©s en ciudadanos americanos por naturalizacià ³n. Sin embargo, la peticià ³n de naturalizacià ³n puede rechazarse si el solicitante no se ha registrado para los Servicios Selectivos cuando tenà ­a la obligacià ³n de hacerlo. Nueva regulacià ³n sobre asilo y cà ³mo protegerse ante fraudes Por directiva del presidente Donald Trump del 9 de noviembre de 2019 las personas que crucen ilegalmente la frontera que separa Mà ©xico de Estados Unidos no pueden bajo ningà ºn caso solicitar asilo. Temporalmente, esta orden est suspendida por orden de un juez federal esperando una resolucià ³n final sobre su aplicacià ³n o revocacià ³n. Segà ºn la orden de Trump, se prevà © que las personas que son agarradas tras cruzar ilegalmente la frontera sern dirigidas a un puerto de entrada para ser procesadas y ahà ­ se decidir quà © se hace con ellas. Solamente aquellas personas que puedan demostrar miedo razonable de ser perseguidas o torturadas si son regresadas a sus paà ­ses podrà ­an solicitar el alivio de suspensià ³n de la deportacià ³n, conocido en inglà ©s como withholding of removal, pero no asilo. Por otra parte, es muy importante evitar ser và ­ctima de un fraude si se ha solicitado asilo. Cabe destacar que as reglas sobre empleo son las explicadas en este artà ­culo. El solicitante no deberà ­a dejarse influenciar por las opiniones de otras personas que dicen que sà ­ se puede trabajar desde el momento en que se presenta la solicitud. Eso era asà ­ hace aà ±os. Pero la ley ha cambiado y ya no es asà ­. Para asegurarse de conocer lo bsico se recomienda tomar este test de respuestas mà ºltiples sobre el asilo y encontrar asà ­ respuesta a tus dudas e inquietudes.  ¿Cà ³mo encontrar asistencia legal a bajo costo o gratuita? Si el solicitante no puede pagar a un abogado, numerosas organizaciones brindan asesorà ­a legal a solicitantes de asilo gratis o a bajo costo. Lo importante es elegir a una organizacià ³n especialista en asilo y de excelente reputacià ³n. Este artà ­culo es solo informativo. No es asesorà ­a legal.

Controversy Analysis Essay Example | Topics and Well Written Essays - 750 words

Controversy Analysis - Essay Example While leadership goals are a part and parcel of education system in this country, understanding the future implications of the education system in the career of a person is very important. Therefore, bringing out leadership qualities in a person must be accompanied by standards of leadership that he or she achieves to meet (Tyack, 1990, 188). When such set standards are used, the extent to which a person can handle leadership challenges becomes clear to the employer. One must remember that even if a person is highly educated, he or she might still lack superb leadership qualities. Therefore, instead of going by grades and academic records, if student leadership skills are quantified, then right candidates get the right degree of job (Berliner, 2013, 206). The main goal of education stays ambiguous even today. There are several definitions of a goal but if a goal decides whether the process of education has been fruitful for the country, then its goals will be different than if the process decides if education has been fruitful for the individual student. Setting up goals on a national level, that focus on individual fulfillment, will help diminish income inequality in the society (Labaree, 1997, 40). Teachers, trainers and mentors need to have a good grasp of the goal or aim of holding a training session or simply completing the class course (Elmore, 2000, 16). Yes, just as redefining educational goals is of prime most importance today, constantly reminding teachers of how well they need to fulfill these goals is also important. Educators have to be told why they need to exercise values of neutrality and strict assessment in grading and placing their students, to be able to remove income inequality. Although their contribution is going to be of less importance owing to inexperience, student involvement in curriculum and assessment protocol decisions is a healthy way to encourage participation and extract performance.

Challenges and benefits for community health nurses Essay

Challenges and benefits for community health nurses - Essay Example In addition, community nurses educate the general community regarding various diseases, how to prevent them and how to live healthy while suffering from certain diseases. According to Savage et al. (2006) this is because, most people in the community lack the information on how to address the various diseases that affect them. However, community nurses often have various challenges with regards to how they carry basic operations in the job description. One of the main challenges that community nurses face is the exposure to infectious diseases in the course of their work. Community nurses provide healthcare in all social settings including the community, churches, schools and even the homeless. In addition, community nurses address complex health problems including delivering healthcare to people living with HIV/AIDS. Under such circumstances, there is no guarantee as to whether the nurses will be infected with infectious diseases. In addition, various protective measures to prevent such an occurrence are not adequate to address the health safety of community nurses. Community nurses also face the challenge of an unresponsive society. Some communities have strong cultural and religious beliefs that affect their attitude and perceptions regarding the healthcare services. Convincing such people in the commu nity on the importance of accessing healthcare services is a huge challenge for community nurses. Savage, C. L., Xu, Y., Lee, R., Rose, B. L., Kappesser, M., & Anthony, J. S. (2006). A Case Study in the Use of Community†Based Participatory Research in Public Health Nursing. Public Health Nursing, 23(5),

Comparison of Pneumonia Management Methods

Comparison of Pneumonia Management Methods INTRODUCTION 1.1 Background: Pneumonia is the inflammation and consolidation of lung tissue due to an infectious agent (Marrie TJ, 1994). Pneumonia has the highest mortality rate among infectious diseases and represents the fifth leading cause of death (Brandstetter, 1993). Pneumonia causes excess morbidity, hospitalization, and mortality, especially among the elderly, the fastest growing sector of the population.According to first- or second-listed diagnosis, approximately 1 million persons were discharged from short-stay hospitals after treatment for pneumoniain the United States in 1990, and elderly persons aged 65 years or more accounted for 52% of all pneumonia discharges (Fedson Musher, 1994). Pneumonia has the highest mortality rate among infectious diseases and represents the fifth cause of death (Brandstltter, 1993). In addition fine (2000) reported that lower respiratory tract infections affect three million persons annually and is the leading cause of death of infection in the United States. †¢ Pneumonia represented one of the 10th leading causes of hospitalization and deaths in Malaysia through 1999-2006 (Ministry of Health, Malaysia, 1999, 2000, 2001, 2002b, 2003, 2004, 2005band 2006b) Because of differences in pathogenesis and causative micro-organisms, pneumonia is often divided into: hospital acquired and community-acquired pneumonia.Community acquired pneumonia (CAP) is caused mainly by streptococcus pneumoniae. Its symptoms include coughing (with or without sputum production), change in colour of respiratory secretion, fever, and pleuritic chest pain (Fine, 2000). Nosocomial pneumonia or hospital acquired pneumonia is the second most common nosocomial infection in the United States and it causes the highest rates of morbidity and mortality. It is caused mainly by streptococcus pneumoniae and pseudomonas aeruginosa. The highest mortality rates occurred in patients with pseudomonas aeruginosa or acineobacter infection. It is characterized by fever and purulent respiratory secretion. Nosocomial pneumonia results in increase length of hospitalization and cost of treatment (Kashuba, 1999; Levison, 2003; Wilks et al., 2003). The clinical criteria for the diagnosis o f pneumonia include chest pain, cough, or auscultatory findings such as rales or evidence of pulmonary consolidation, fever or leucocytosis. In addition, there must be radiographic evidence, such as the presence of new infiltrates on chest radiograph, and laboratory evidence that supports the diagnosis. Because of differences in pathogenesis and causative micro-organisms, pneumonia is often divided in hospital acquired and community-acquired pneumonia. Pneumonia developing outside the hospital is referred to as community-acquired pneumonia (CAP). Pharmacoeconomic study Pharmacoeconomics is defined as the description and analysis of costs of drug therapy or clinical service to health care systems and society (Bootman et al., 1996). It has risen up as the discipline with the increase interst in calculating the value and costs of medicines (Sanches, 1994). Cost is defined as the value of resources consumed by the program or drug therapy of interest while a consequence is defined as the effect, outputs, or outcomes of a program. When identifying the costs associated with a product or service, all possible costs that include or related to the study are calculated (Sanchez, 1994). With the increase in financial pressure to hospitals to minimize their medical care costs, pharmacoeconomics can define costs and benefits of both expensive drug therapies and pharmacy based clinical services (Destache, 1993; Touw, 2005).Furthermore pharmacoeconomics can assist practitioners in balancing cost and quality that may result in improving patient care and cost saving to the institution (Sanches, 1994). Bootman and Harison (1997) stated that pharmacoeconomics and outcome research are very important to determine the efficient way to present a quality care at realistic rate. They suggested that pharmacoeconomics should have a remarkable authority on the delivery and financing of health care throughout the world. Different methods have been used to perform pharmacoeconomics analysis which includes: Cost-benefit analysis: Cost-benefit analysis two or more alternatives that do not have the same outcome measures. It measures all costs and benefits of a program in monetary terms (Bootman et al., 1996; Fleurence, 2003). Cost-benefit analysis could play a major role in identifying the specific costs and benefits associated with the pneumonia. Cost-effective analysis Cost-effective analysis compares alternatives that differ in safety, efficacy and outcome. Cost is measured in monetary terms, while outcome is measured in specific objectives or natural units. The outcome are expressed in terms of the cost per unit of success or effect (Bootman et al., 1996). Cost-utility analysis Cost-utility analysis compares treatment alternatives; benefits are measured in terms of quality of life, willingness to pay, and patient preference for one intervention over another, while cost is measured in monetary terms. It has some similarity to cost-effectivness with more concentration on patient view. As an example, looking for new druig therapy; benefits can built-in together with expected risks. Cost-minimization analysis Cost-minimization analysis is one of the simplest forms of pharmacoeconomics analysis. It is used when two or more alternatives are assumed to be equivalent in terms of outcomes but differ in the cost which is measured in monetary terms (Fleurence, 2003). Cost of illness analysis Cost of illness analysis is the determination of all costs of aparticular disease, which include both direct and indirect costs. Since both costs were calculated, an economic evaluation for the disease can be performed successfully. It has been used for evaluating many diseases (Bootman et al., 1996). 1.2 Study problems and rationale The management of pneumonia is very straight forward. However this is not always true for the diagnosis and selection of therapy. As there are some issues related to pneumonia that need to be addressed : The first issue pertains to the inappropriate diagnosis of the pneumonia. Some physicians do not properly identify the causative organism, I.e, whether, it is bacterial or viral. Bartlet et al (1998) found that the viral infections have been associated with at least 10% to 15 % of CAP in hospitalized adults (Bartlet et al, 1998). Secondly is the use of inappropriate medications. The prescription of inappropriate or un-indicated drug therapy such as the prescription of antibiotics for pneumonia caused by nonbacterial infection may increase the incidence of bacterial resistance (Steinman, 2003). Thirdly the adherence to guidelines improves quality of care and reduces the length of hospital stay (Marrie TJ et al, 2000). Fourthly the adherence to guidelines reduces the cost of treating pneumonia (Feagan BG, 2001). Fifthly Teaching hospitals are widely perceived to provide good outcome, and that reputation is thought to justify these institutions comparatively higher charges relative to non-teaching (general) hospitals. Despite their reputation for specialized care, teaching hospitals have traditionally relied on revenue from routine services, such as treatment of pneumonia, and the costs of specialized services and medical training. However, with managed care and competition creating pressures for cost containment, these higher costs have come into question: Do a teaching hospital provide good outcome for management of pneumonia, or do a general hospital provide comparable outcome at lower costs? 1.3 Significance of the Study This study has the following important issues: To the researchers: Several studies have compare the management of pneumonia in a university hospital versus a general hospital, but most of these studies were conducted in the USA and other parts of the world. There are no published studies in Malaysia or Asia to our knowledge. This study also provides the difference in the outcome, cost and cost-effectivness of treating pneumonia between a university hospital and a general hospital. To the practitioners: This study will provide information about the adherence to guidelines will reduce the length of hospital stay, reduce the cost of treating pneumonia and improve outcomes of treating pneumonia. To the patients: This study attempts to highlight the benefits associated with adherence to the guidelines. To the policy makers: This study will help policy makers to develop new strategies for management of pneumonia. This study will help policy makers to develop new guideline for management of pneumonia according to the microorganisms and the population in Malaysia. This study also provides the difference in the management of pneumonia between a university hospital and a general hospital. This study will provide information about how we can reduce the length of hospital stay, reduce the cost of treating pneumonia and improve outcomes of treating pneumonia. The results of this study will help in improving the management of pneumonia. It is the time to know whether a university hospital (H-USM) provide good outcome for treating pneumonia or do a general hospital (Penang-GH) provide comparable outcome at lower costs. By analyzing the cost and effectiveness of the regimens being used, the most effective therapy can be defined and the information can be offered to the policy makers to improve the deciosion making in treating pneumonia. The study will be able to help on: How we can make the drug therapy cost effective keeping effectiveness and outcome in our mind and try to suggest the best and most appropriate drug therapy which should be cost effective which help to decrease the financial burden on patients as well as Ministry Of health. This study will help to suggest how we can reduce the cost of therapy of treating pneumonia. The study will be able to provide data on: The incidence of pneumonia in (H-USM and Penang-GH). The most common organisms causing pneumonia in (H-USM and Penang-GH). The pattern of drugs used and management of pneumonia in in (H-USM and Penang-GH). The outcome of treating pneumonia in (H-USM and Penang-GH). The cost of treating pneumonia in (H-USM and Penang-GH). The cost-effectivness of treating pneumonia in (H-USM and Penang-GH). Whether a university hospital provide a good outcome for management of pneumonia, or a general hospital provide comparable quality at lower costs. 1.4 Hypothesis of the Study: H0: There is no significant difference of the management of pneumonia between a universiry hospital (H-USM) and a general hospital (Penang-GH). H1: There is a significant difference of the management of pneumonia between a universiry hospital (H-USM) and a general hospital (Penang-GH). 1.5 Aim of the study The aim of this study is to compare the management of pneumonia in a university hospital (H-USM) versus a general hospital (Pinanag-GH). 1.6 Objectives The objectives of this study are: To compare the incidence of pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the most common organisms associated with pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the drug therapy for pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the outcome of treating pneumonia (mortality rate, length of hospitalization, pneumonia related symptoms at discharge and complications of pneumonia) at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the cost of treating pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the cost-effectivness of treating pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). 1.7 Research Questions What are the difference between the organisms that is commonly associated with pneumonia at H-USM and Penang-GH? What are the difference between the antibiotics that is commonly used for the treatment of pneumonia at H-USM and Penang-GH? What are the difference between the outcome of treating pneumonia (mortality rate, length of hospitalization, pneumonia related symptoms at discharge and complications of pneumonia) at H-USM and Penang-GH? What are the difference between the cost of treating pneumonia at H-USM and Penang-GH? And how can these costs be reduced? What are the difference between the cost-effectivness of treating pneumonia at H-USM and Penang-GH? Do a university hospital (H-USM) provide good outcome for treating pneumonia or do a general hospital (Penang-GH) provide comparable outcome at lower costs? CHPTER 2 LITERATURE REVIEW 2.1 Community-acquired pneumonia 2.1.1 Introduction Community-acquired pneumonia (CAP) is defined as an acute infection of the pulmonary parenchyma that is associated with at least some symptoms of acute infection, a new infiltrate on chest x-ray or auscultatory findings such as altered breath sounds and/or localized rales in community-dwelling patients (Infectious Diseases Society of America 2000). It is a common condition that carries a high burden of mortality and morbidity, particularly in elderly populations. Although most patients recover without sequellae, CAP can take a very severe course, requiring admission to an intensive care unit (ICU) and even leading to death. According to US data, it is the most important cause of death from infectious causes and the sixth most important cause of death overall (Adams et al. 1996). Even though the mortality from pneumonia decreased rapidly in the 1940s after the introduction of antibiotic therapy, it has remained essentially unchanged since then or has even increased slightly (MMWR 1995 ). Furthermore, significant costs are associated with the diagnosis and management of CAP. Between 22% and 42% of adults with CAP are admitted to hospital, and of those, 5% to 10% need to be admitted to an ICU (British Thoracic Society 2001). In the US, it is estimated that the total cost of treating an episode of CAP in hospital is about USD $ 7500, which is approximately 20 times more than the cost of treating a patient on an outpatient basis (Lave et al. 1999). CAP also contributes significantly to antibiotic use, which is associated with well-known problems of resistance. In treating patients with CAP, the choice of antibiotic is a difficult one. Factors to be considered are the possible etiologic pathogen, the efficacy of the substance, potential side-effects, the treatment schedule and its effect on adherence to treatment as well as the particular regional resistance profile of the causative organism and the co-morbidities that might influence the range of potential pathogens (such as in cystic fibrosis) or the dosage (as in the case of renal insufficiency). It may be a primary disease occurring at random in healthy individuals or may be secondary to a predisposing factor such as chronic lung disease or diabetes mellitus. CAP represents a broad spectrum of severity, ranging from mild pneumonia that can be managed by general practitioners outside the hospital to severe pneumonia with septic shock needing treatment in intensive care unit. Depending on severity of illness, about 20% of patients with pneumonia need hospitalization and approximately 1% of all CAP patients require treatment in ICU. Elderly persons and those with underlying conditions, such as cerebro and cardiovascular diseases, chronic obstructive pulmonary disease (COPD) and alcoholism, are at increased risk for developing lower respiratory tract infections and complicated courses of infection. 2.1.2 Definition: Community-Acquired pneumonia (CAP) is defined as inflammation and consolidation of lung tissue induced by infectious microbes such as bacteria, viruses, or parasites. When the onset of symptoms and signs of this disease is before or within 48 hours after admission, it is considered as CAP (Bartlett JG et al., 1995). 2.1.3 Epidemiology Incidence: In the industrialized world, the annual incidence of CAP in community dwelling adults is estimated at 5 to 11 cases per 1000 adult population (British Thoracic Society 2001). The incidence is known to vary markedly with age, being higher in the very young and the elderly. In one Finnish study, the annual incidence for people aged 16-59 years was 6 cases per 1000 population, for those 60 years and older it was 20 per 1000, and for people aged 75 and over, 34 per 1000 (Jokinen et al. 1993). Annual incidences of 30-50 per 1000 population have been reported for infants below 1 year of age (Marrie 2001). Seasonal variations in incidence are also significant, with a peak in the winter months (Marrie 2001). The annual incidence of CAP requiring hospitalisation has been estimated at 1 to 4 patients per 1000 population (Marrie 1990, Fine et al. 1996). The proportion of patients requiring hospitalisation varies from country to country and across studies and has been estimated as ranging anywhe re between 15% and 56% (Foy et al. 1973, Minogue et al. 1998). Of those, 5% to 10% required admission to an intensive care unit (ICU) (British Thoracic Society Research Committee and Public Health Laboratory Service 1992, Torres et al. 1991). Conversely, about 8% to 10% of admissions to a medical ICU are due to severe CAP (Woodhead et al. 1985). Community acquired pneumonia (CAP) is a leading infectious disease cause of death throughout the world (WHO Statistical Information System (WHOSIS). WHO Mortality Database. Released: January 2005; Health, United States, 2005; Annual Report, Hong Kong, 2003/2004). Adult community-acquired pneumonia is a serious, life-threatening illness that affects more than 3 million people each year and accounts for more than half a million annual hospital admissions in the United States alone (Lynch JP, 1992). Each year, more than 900 000 cases of pneumonia occur in the United States, accounting for nearly 3% of all hospital admissions,(National Hospital Discharge Survey, 1988) and about 50 000 people die as a result of community-acquired pneumonia (Farr BM et al 203). Bartlet et al (1998) found that viral infections have been associated with at least 10% to 15 % of CAP in hospitalized adults. Adult community-acquired pneumonia is a serious, life-threatening illness that affects more than 3 million people each year and accounts for more than half a million annual hospital admissions in the United States alone. Each year, more than 900 000 cases of pneumonia occur in the United States, accounting for nearly 3% of all hospital admissions, and about 50 000 people die as a result of community-acquired pneumonia. In the USA, community acquired pneumonia is the fifth leading cause of death in people over the age of 65 years and an estimated 60 000 seniors die annually. Most of the excess deaths and hospitalizations due to lower respiratory infections occur in older adults, as reflected by the more than 44 000 hospitalizations for pneumonia and influenza in people aged 65 and older in 1997 in Canada. It is estimated that the age-specific incidence of pneumonia increases from 15.4 cases per 1000 in those aged 60-74 years to 34.2 for those 75 years and older. Residents of long-term care facilities, a distinct subpopulation of elderly people, are at particularly high risk for developing nursing-home acquired pneumonia. Health costs for this sector are growing at an accelerated rate as the age of dea th increases. Thirteen percent of the population is over the age of 65 in the United States and this is expected to increase to 20% by 2030. In Canada, the proportion of individuals over the age of 65 is expected to rise to 20% in the year 2021. Presently, while making up 12% of the Canadian population, older adults account for 31% of acute hospital days and half of all hospital stays. To meet their health-care needs and alleviate the burden onthe health-care system, we must improve our understanding of the management and prevention of pneumonia in this age group. Elderly people constitute an ever-increasing proportion of the population. CAP has traditionally been recognized as problems that particularly affect the older individuals. According to western studies, the overall rate of pneumonia requiring hospitalization increase with age, from 1 per 1,000 persons in the general population but increases to 12 per 1,000 persons for those over age 75 years3. As the population of those ov er age 65 years is predicted to rise from its current level of 11% to 25 % of the total population in the year 20504, respiratory tract infection will assume a greater degree of importance to the overall public health. In Hong Kong, pneumonia was the fourth leading death from a specific diagnosis in 2001. A total of 3026 people died of pneumonia in 2001 which 1526 cases were male. Out of the 3026 deaths, 2794 patients were 65 or older which accounted for more than 90% of the total death. Pneumonia in the elderly population is a major cause of morbidity and mortality and in some series represents the leading cause of death. The annual cost of treating patients age > 65 years with pneumonia to be $4.8 billion, compared with $3.6 billion for those 85 years need help with bathing and 10% need help in using the toilet and transferring. The present of any or all of following identifies elderly persons at greatest risk for functional decline: pressure ulcer, cognitive impairment, functiona l impairment, and low level of social activity. The attack rate for pneumonia is highest among those in nursing homes. It is found that 33 of 1,000 nursing home residents per year required hospitalization for treatment of pneumonia, compared with 1.14 of 1,000 adults living in the community. Pneumonia is a major cause of morbidity and mortality worldwide. In the UK as a whole, pneumonia is responsible for over 10% of all deaths (66,581 deaths in 2001), the majority of which occur in the elderly. Community-acquired pneumonia (CAP) remains a common cause of morbidity. Because CAP also is a potentially fatal disease, even in previously healthy persons, early appropriate antibiotic treatment is vital. In Japan, pneumonia is the fourth leading cause of death, and from 57 to 70 persons per 100,000 populations died per year of this disease in the last decade. Community acquired pneumonia (CAP) is a leading infectious disease cause of death throughout the world, including Hong Kong, Pneumonia is the second most common infectious disease in Thailand. Whereas diarrhea is more common, pneumonia is associated with more fatalities. CAP remains the leading cause of death due to infectious diseases, with an annual incidence ranging 1.6-10.6 per 1,000 adult populations in Europe According to the Ministry of Health Malaysia (MOH), pneumonia is the 5th cause of death in Malaysia and the 4th cause of hospitalization. A prospective observational study by Jae et al (2007) of 955 cases of adult CAP in 14 hospitals in eight Asian countries found that the overall 30-day mortality rate was 7.3%. A prospective study by Liam CK et al (2001) of 127 cases of CAP in Malaysia found that the Mortality from CAP is more likely in patients with comorbidity and in those who are bacteraemic. A prospective study by LOH et al (2004) of 108 cases of adult CAP in urban-based university teaching hospital in Malaysia found that the mortality rate from CAP in hospital was 12%. 2.1.4 Syndromes of CAP The presence of various signs and symptoms and physical findings varies according to the age of the patients, therapy with antibiotics before presentation, and the severity of illness. Patients with pneumonia usually present with cough (>90%), dyspnea (66%), sputum production (66%% pleuritic chest pain (50%), and chills is present in 40-70% and rigor in 15%. However, a variety of nonrespiratory symptoms can also predominate in pneumonia cases, including fatigue (91%), anorexia (71%), sweating (69%), and nausea (41%). Metlay et al. (1997c) divided 1812 patients with CAP into four age groups: 18 through 44 years (43%), 45 through 64 years (25%), 65 through 74 years (17%), and 75 years or older (15%). For 17 of the 18 recorded symptoms there were significant decreases in reported prevalence with increasing age (p 37 °C at presentation. Crackles were present on auscultation in 80% of patients, and rhonchi in 34% to 47% (more common in the nursing home patients). About 25% had the physical findings of dullness to percussion, bronchial breathing, whispered pectoriloquy, and aegophony. Alteration in mental status was common. Marrie and coworkers (1989) reported confusion in 48% of the patients with nursing home-acquired pneumonia and in 30% of the other patients with CAP. Fine and colleagues (1998) define altered mental status as stupor, coma, or confusion representing an acute change from the usual state prior to presentation with pneumonia. This was present in 17.3% of the hospitalized patients. The decrease in symptoms with increasing age, tachypnea increased with increasing age (Metlay et al., 1997c). Thirty-six percent of 780 patients with CAP in the 18-44 year age group had tachypnea on admission versus 65% of the 280 patients who were = 75 years old. There were minimal differences in the proportion of patients with tachycardia and hyperthermia in the different age groups Pneumonia in the elderly are quite different from that in a younger population. These differences are due to age-related alterations in immunology, different epidemiology and bacteriology. It is important to remember that pneumonia in the elderly may report fewer respiratory signs and symptoms. The clinical presentation may be more subtle than in younger population, with more gradual onset, less frequent complaints of chill and rigors, and less fever. The classical finding of cough, fever, and dyspnea may be absent in over half of elderly patients8. Instead they may be manifest as delirium, a decline in f unctional status, weakness, anorexia, abdominal pain, or decrease general condition. The incidence of fever may decline with age, and the degree of fever appears lower in old population10. Tachypnea which respiration rate greater than 24-30 breaths per minute is noted more frequently in up to 69% of patients. Although rales are common and are noted in 78% of patients, signs of true consolidation are found in only 29%. Bacteremia, metastatic foci of infection and death are more frequent in older populations. As many elderly present with non-specific clinical symptoms and nonspecific functional decline that makes an accurate diagnosis difficult and may lead a life-threatening delay of diagnosis and therapy. Metlay et al. compared the prevalence of symptoms and signs of pneumonia in a cohort of 1812 patients and found that patients aged 65-74 years and over 75 years had 2.9 and 3.3 fewer symptoms, respectively, than those aged 18 through 44 years. The reduced prevalence of symptoms was most pronounced for symptoms related to febrile response (chills and sweats) and pain (chest, headache, and myalgia). These findings are consistent with those of Marrie et al. demonstrating reduced prevalence of non-respiratory symptoms among elderly patients. In a retrospective chart review by Johnson et al., the presence of dementia seemed to account for non-specific symptoms. However the sample size of the study was small and precluded a multivariable analysis. Roghmann et al found a significant inverse correlation between age and initial temperature in 320 older patients hospitalized for pneumonia. Evidence therefore does exist for a less distinct presentation of nonrespiratory symptoms and signs of pneumonia in the elderly. 2.1.5 Radiographic findings in CAP Radiographic changes usually cannot be used to distinguish bacterial from nonbacterial pneumonia, but they are often important for diagnosis of CAP, evaluating the severity of illness, determining the need for diagnostic studies, and selecting antibiotic agents. A chest radiograph usually shows lobar or segmental opacification in bacterial pneumonias and in the majority of atypical infections. Patchy peribronchial shadowing or more diffuse nodular or ground-glass opacification is seen less commonly, particularly in viral and atypical infections. The lower lobes are most commonly affected in all types of pneumonia. Small pleural effusions can be detected in about one-quarter of cases. Multilobar pneumonia is a feature of severe disease, and spread to other lobes despite appropriate antibiotics is seen in Legionella and M. pneumoniae infection. Hilar lymphadenopathy is unusual except in Mycoplasma pneumonia, particularly in children. Cavitation is uncommon but is a classic feature of S . aureus and S. pneumoniae infections. False negative results can be attributed to dehydration, evaluation during the first 24 hours, pneumonia due to Pneumocystis carinii, or pneumonia with profound neutropenia. 2.1.6 Etiology: More than 100 microorganisms have been identified so far as potential causative agents of CAP (Marrie 2001). They can be classified according to their biological characteristics as either bacteria, mycoplasma and other intracellular organisms, viruses, fungi and parasites. The most common causative agent of CAP is the bacteriumStreptococcus pneumoniae, which is implicated in 20% to 75% of cases of CAP (Marrie 2001) and about 66% of bacteremic pneumonia (Infectious Diseases Society of America 2000). Another causative bacterium is Haemophilus influenzae. So called â€Å"atypical† organisms have also been implicated as causal agents. These include Chlamydia pneumoniae, Mycoplasma pneumoniae and Legionella pneumophila (Marrie 2001). Influenza is the most common serio Comparison of Pneumonia Management Methods Comparison of Pneumonia Management Methods INTRODUCTION 1.1 Background: Pneumonia is the inflammation and consolidation of lung tissue due to an infectious agent (Marrie TJ, 1994). Pneumonia has the highest mortality rate among infectious diseases and represents the fifth leading cause of death (Brandstetter, 1993). Pneumonia causes excess morbidity, hospitalization, and mortality, especially among the elderly, the fastest growing sector of the population.According to first- or second-listed diagnosis, approximately 1 million persons were discharged from short-stay hospitals after treatment for pneumoniain the United States in 1990, and elderly persons aged 65 years or more accounted for 52% of all pneumonia discharges (Fedson Musher, 1994). Pneumonia has the highest mortality rate among infectious diseases and represents the fifth cause of death (Brandstltter, 1993). In addition fine (2000) reported that lower respiratory tract infections affect three million persons annually and is the leading cause of death of infection in the United States. †¢ Pneumonia represented one of the 10th leading causes of hospitalization and deaths in Malaysia through 1999-2006 (Ministry of Health, Malaysia, 1999, 2000, 2001, 2002b, 2003, 2004, 2005band 2006b) Because of differences in pathogenesis and causative micro-organisms, pneumonia is often divided into: hospital acquired and community-acquired pneumonia.Community acquired pneumonia (CAP) is caused mainly by streptococcus pneumoniae. Its symptoms include coughing (with or without sputum production), change in colour of respiratory secretion, fever, and pleuritic chest pain (Fine, 2000). Nosocomial pneumonia or hospital acquired pneumonia is the second most common nosocomial infection in the United States and it causes the highest rates of morbidity and mortality. It is caused mainly by streptococcus pneumoniae and pseudomonas aeruginosa. The highest mortality rates occurred in patients with pseudomonas aeruginosa or acineobacter infection. It is characterized by fever and purulent respiratory secretion. Nosocomial pneumonia results in increase length of hospitalization and cost of treatment (Kashuba, 1999; Levison, 2003; Wilks et al., 2003). The clinical criteria for the diagnosis o f pneumonia include chest pain, cough, or auscultatory findings such as rales or evidence of pulmonary consolidation, fever or leucocytosis. In addition, there must be radiographic evidence, such as the presence of new infiltrates on chest radiograph, and laboratory evidence that supports the diagnosis. Because of differences in pathogenesis and causative micro-organisms, pneumonia is often divided in hospital acquired and community-acquired pneumonia. Pneumonia developing outside the hospital is referred to as community-acquired pneumonia (CAP). Pharmacoeconomic study Pharmacoeconomics is defined as the description and analysis of costs of drug therapy or clinical service to health care systems and society (Bootman et al., 1996). It has risen up as the discipline with the increase interst in calculating the value and costs of medicines (Sanches, 1994). Cost is defined as the value of resources consumed by the program or drug therapy of interest while a consequence is defined as the effect, outputs, or outcomes of a program. When identifying the costs associated with a product or service, all possible costs that include or related to the study are calculated (Sanchez, 1994). With the increase in financial pressure to hospitals to minimize their medical care costs, pharmacoeconomics can define costs and benefits of both expensive drug therapies and pharmacy based clinical services (Destache, 1993; Touw, 2005).Furthermore pharmacoeconomics can assist practitioners in balancing cost and quality that may result in improving patient care and cost saving to the institution (Sanches, 1994). Bootman and Harison (1997) stated that pharmacoeconomics and outcome research are very important to determine the efficient way to present a quality care at realistic rate. They suggested that pharmacoeconomics should have a remarkable authority on the delivery and financing of health care throughout the world. Different methods have been used to perform pharmacoeconomics analysis which includes: Cost-benefit analysis: Cost-benefit analysis two or more alternatives that do not have the same outcome measures. It measures all costs and benefits of a program in monetary terms (Bootman et al., 1996; Fleurence, 2003). Cost-benefit analysis could play a major role in identifying the specific costs and benefits associated with the pneumonia. Cost-effective analysis Cost-effective analysis compares alternatives that differ in safety, efficacy and outcome. Cost is measured in monetary terms, while outcome is measured in specific objectives or natural units. The outcome are expressed in terms of the cost per unit of success or effect (Bootman et al., 1996). Cost-utility analysis Cost-utility analysis compares treatment alternatives; benefits are measured in terms of quality of life, willingness to pay, and patient preference for one intervention over another, while cost is measured in monetary terms. It has some similarity to cost-effectivness with more concentration on patient view. As an example, looking for new druig therapy; benefits can built-in together with expected risks. Cost-minimization analysis Cost-minimization analysis is one of the simplest forms of pharmacoeconomics analysis. It is used when two or more alternatives are assumed to be equivalent in terms of outcomes but differ in the cost which is measured in monetary terms (Fleurence, 2003). Cost of illness analysis Cost of illness analysis is the determination of all costs of aparticular disease, which include both direct and indirect costs. Since both costs were calculated, an economic evaluation for the disease can be performed successfully. It has been used for evaluating many diseases (Bootman et al., 1996). 1.2 Study problems and rationale The management of pneumonia is very straight forward. However this is not always true for the diagnosis and selection of therapy. As there are some issues related to pneumonia that need to be addressed : The first issue pertains to the inappropriate diagnosis of the pneumonia. Some physicians do not properly identify the causative organism, I.e, whether, it is bacterial or viral. Bartlet et al (1998) found that the viral infections have been associated with at least 10% to 15 % of CAP in hospitalized adults (Bartlet et al, 1998). Secondly is the use of inappropriate medications. The prescription of inappropriate or un-indicated drug therapy such as the prescription of antibiotics for pneumonia caused by nonbacterial infection may increase the incidence of bacterial resistance (Steinman, 2003). Thirdly the adherence to guidelines improves quality of care and reduces the length of hospital stay (Marrie TJ et al, 2000). Fourthly the adherence to guidelines reduces the cost of treating pneumonia (Feagan BG, 2001). Fifthly Teaching hospitals are widely perceived to provide good outcome, and that reputation is thought to justify these institutions comparatively higher charges relative to non-teaching (general) hospitals. Despite their reputation for specialized care, teaching hospitals have traditionally relied on revenue from routine services, such as treatment of pneumonia, and the costs of specialized services and medical training. However, with managed care and competition creating pressures for cost containment, these higher costs have come into question: Do a teaching hospital provide good outcome for management of pneumonia, or do a general hospital provide comparable outcome at lower costs? 1.3 Significance of the Study This study has the following important issues: To the researchers: Several studies have compare the management of pneumonia in a university hospital versus a general hospital, but most of these studies were conducted in the USA and other parts of the world. There are no published studies in Malaysia or Asia to our knowledge. This study also provides the difference in the outcome, cost and cost-effectivness of treating pneumonia between a university hospital and a general hospital. To the practitioners: This study will provide information about the adherence to guidelines will reduce the length of hospital stay, reduce the cost of treating pneumonia and improve outcomes of treating pneumonia. To the patients: This study attempts to highlight the benefits associated with adherence to the guidelines. To the policy makers: This study will help policy makers to develop new strategies for management of pneumonia. This study will help policy makers to develop new guideline for management of pneumonia according to the microorganisms and the population in Malaysia. This study also provides the difference in the management of pneumonia between a university hospital and a general hospital. This study will provide information about how we can reduce the length of hospital stay, reduce the cost of treating pneumonia and improve outcomes of treating pneumonia. The results of this study will help in improving the management of pneumonia. It is the time to know whether a university hospital (H-USM) provide good outcome for treating pneumonia or do a general hospital (Penang-GH) provide comparable outcome at lower costs. By analyzing the cost and effectiveness of the regimens being used, the most effective therapy can be defined and the information can be offered to the policy makers to improve the deciosion making in treating pneumonia. The study will be able to help on: How we can make the drug therapy cost effective keeping effectiveness and outcome in our mind and try to suggest the best and most appropriate drug therapy which should be cost effective which help to decrease the financial burden on patients as well as Ministry Of health. This study will help to suggest how we can reduce the cost of therapy of treating pneumonia. The study will be able to provide data on: The incidence of pneumonia in (H-USM and Penang-GH). The most common organisms causing pneumonia in (H-USM and Penang-GH). The pattern of drugs used and management of pneumonia in in (H-USM and Penang-GH). The outcome of treating pneumonia in (H-USM and Penang-GH). The cost of treating pneumonia in (H-USM and Penang-GH). The cost-effectivness of treating pneumonia in (H-USM and Penang-GH). Whether a university hospital provide a good outcome for management of pneumonia, or a general hospital provide comparable quality at lower costs. 1.4 Hypothesis of the Study: H0: There is no significant difference of the management of pneumonia between a universiry hospital (H-USM) and a general hospital (Penang-GH). H1: There is a significant difference of the management of pneumonia between a universiry hospital (H-USM) and a general hospital (Penang-GH). 1.5 Aim of the study The aim of this study is to compare the management of pneumonia in a university hospital (H-USM) versus a general hospital (Pinanag-GH). 1.6 Objectives The objectives of this study are: To compare the incidence of pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the most common organisms associated with pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the drug therapy for pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the outcome of treating pneumonia (mortality rate, length of hospitalization, pneumonia related symptoms at discharge and complications of pneumonia) at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the cost of treating pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the cost-effectivness of treating pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). 1.7 Research Questions What are the difference between the organisms that is commonly associated with pneumonia at H-USM and Penang-GH? What are the difference between the antibiotics that is commonly used for the treatment of pneumonia at H-USM and Penang-GH? What are the difference between the outcome of treating pneumonia (mortality rate, length of hospitalization, pneumonia related symptoms at discharge and complications of pneumonia) at H-USM and Penang-GH? What are the difference between the cost of treating pneumonia at H-USM and Penang-GH? And how can these costs be reduced? What are the difference between the cost-effectivness of treating pneumonia at H-USM and Penang-GH? Do a university hospital (H-USM) provide good outcome for treating pneumonia or do a general hospital (Penang-GH) provide comparable outcome at lower costs? CHPTER 2 LITERATURE REVIEW 2.1 Community-acquired pneumonia 2.1.1 Introduction Community-acquired pneumonia (CAP) is defined as an acute infection of the pulmonary parenchyma that is associated with at least some symptoms of acute infection, a new infiltrate on chest x-ray or auscultatory findings such as altered breath sounds and/or localized rales in community-dwelling patients (Infectious Diseases Society of America 2000). It is a common condition that carries a high burden of mortality and morbidity, particularly in elderly populations. Although most patients recover without sequellae, CAP can take a very severe course, requiring admission to an intensive care unit (ICU) and even leading to death. According to US data, it is the most important cause of death from infectious causes and the sixth most important cause of death overall (Adams et al. 1996). Even though the mortality from pneumonia decreased rapidly in the 1940s after the introduction of antibiotic therapy, it has remained essentially unchanged since then or has even increased slightly (MMWR 1995 ). Furthermore, significant costs are associated with the diagnosis and management of CAP. Between 22% and 42% of adults with CAP are admitted to hospital, and of those, 5% to 10% need to be admitted to an ICU (British Thoracic Society 2001). In the US, it is estimated that the total cost of treating an episode of CAP in hospital is about USD $ 7500, which is approximately 20 times more than the cost of treating a patient on an outpatient basis (Lave et al. 1999). CAP also contributes significantly to antibiotic use, which is associated with well-known problems of resistance. In treating patients with CAP, the choice of antibiotic is a difficult one. Factors to be considered are the possible etiologic pathogen, the efficacy of the substance, potential side-effects, the treatment schedule and its effect on adherence to treatment as well as the particular regional resistance profile of the causative organism and the co-morbidities that might influence the range of potential pathogens (such as in cystic fibrosis) or the dosage (as in the case of renal insufficiency). It may be a primary disease occurring at random in healthy individuals or may be secondary to a predisposing factor such as chronic lung disease or diabetes mellitus. CAP represents a broad spectrum of severity, ranging from mild pneumonia that can be managed by general practitioners outside the hospital to severe pneumonia with septic shock needing treatment in intensive care unit. Depending on severity of illness, about 20% of patients with pneumonia need hospitalization and approximately 1% of all CAP patients require treatment in ICU. Elderly persons and those with underlying conditions, such as cerebro and cardiovascular diseases, chronic obstructive pulmonary disease (COPD) and alcoholism, are at increased risk for developing lower respiratory tract infections and complicated courses of infection. 2.1.2 Definition: Community-Acquired pneumonia (CAP) is defined as inflammation and consolidation of lung tissue induced by infectious microbes such as bacteria, viruses, or parasites. When the onset of symptoms and signs of this disease is before or within 48 hours after admission, it is considered as CAP (Bartlett JG et al., 1995). 2.1.3 Epidemiology Incidence: In the industrialized world, the annual incidence of CAP in community dwelling adults is estimated at 5 to 11 cases per 1000 adult population (British Thoracic Society 2001). The incidence is known to vary markedly with age, being higher in the very young and the elderly. In one Finnish study, the annual incidence for people aged 16-59 years was 6 cases per 1000 population, for those 60 years and older it was 20 per 1000, and for people aged 75 and over, 34 per 1000 (Jokinen et al. 1993). Annual incidences of 30-50 per 1000 population have been reported for infants below 1 year of age (Marrie 2001). Seasonal variations in incidence are also significant, with a peak in the winter months (Marrie 2001). The annual incidence of CAP requiring hospitalisation has been estimated at 1 to 4 patients per 1000 population (Marrie 1990, Fine et al. 1996). The proportion of patients requiring hospitalisation varies from country to country and across studies and has been estimated as ranging anywhe re between 15% and 56% (Foy et al. 1973, Minogue et al. 1998). Of those, 5% to 10% required admission to an intensive care unit (ICU) (British Thoracic Society Research Committee and Public Health Laboratory Service 1992, Torres et al. 1991). Conversely, about 8% to 10% of admissions to a medical ICU are due to severe CAP (Woodhead et al. 1985). Community acquired pneumonia (CAP) is a leading infectious disease cause of death throughout the world (WHO Statistical Information System (WHOSIS). WHO Mortality Database. Released: January 2005; Health, United States, 2005; Annual Report, Hong Kong, 2003/2004). Adult community-acquired pneumonia is a serious, life-threatening illness that affects more than 3 million people each year and accounts for more than half a million annual hospital admissions in the United States alone (Lynch JP, 1992). Each year, more than 900 000 cases of pneumonia occur in the United States, accounting for nearly 3% of all hospital admissions,(National Hospital Discharge Survey, 1988) and about 50 000 people die as a result of community-acquired pneumonia (Farr BM et al 203). Bartlet et al (1998) found that viral infections have been associated with at least 10% to 15 % of CAP in hospitalized adults. Adult community-acquired pneumonia is a serious, life-threatening illness that affects more than 3 million people each year and accounts for more than half a million annual hospital admissions in the United States alone. Each year, more than 900 000 cases of pneumonia occur in the United States, accounting for nearly 3% of all hospital admissions, and about 50 000 people die as a result of community-acquired pneumonia. In the USA, community acquired pneumonia is the fifth leading cause of death in people over the age of 65 years and an estimated 60 000 seniors die annually. Most of the excess deaths and hospitalizations due to lower respiratory infections occur in older adults, as reflected by the more than 44 000 hospitalizations for pneumonia and influenza in people aged 65 and older in 1997 in Canada. It is estimated that the age-specific incidence of pneumonia increases from 15.4 cases per 1000 in those aged 60-74 years to 34.2 for those 75 years and older. Residents of long-term care facilities, a distinct subpopulation of elderly people, are at particularly high risk for developing nursing-home acquired pneumonia. Health costs for this sector are growing at an accelerated rate as the age of dea th increases. Thirteen percent of the population is over the age of 65 in the United States and this is expected to increase to 20% by 2030. In Canada, the proportion of individuals over the age of 65 is expected to rise to 20% in the year 2021. Presently, while making up 12% of the Canadian population, older adults account for 31% of acute hospital days and half of all hospital stays. To meet their health-care needs and alleviate the burden onthe health-care system, we must improve our understanding of the management and prevention of pneumonia in this age group. Elderly people constitute an ever-increasing proportion of the population. CAP has traditionally been recognized as problems that particularly affect the older individuals. According to western studies, the overall rate of pneumonia requiring hospitalization increase with age, from 1 per 1,000 persons in the general population but increases to 12 per 1,000 persons for those over age 75 years3. As the population of those ov er age 65 years is predicted to rise from its current level of 11% to 25 % of the total population in the year 20504, respiratory tract infection will assume a greater degree of importance to the overall public health. In Hong Kong, pneumonia was the fourth leading death from a specific diagnosis in 2001. A total of 3026 people died of pneumonia in 2001 which 1526 cases were male. Out of the 3026 deaths, 2794 patients were 65 or older which accounted for more than 90% of the total death. Pneumonia in the elderly population is a major cause of morbidity and mortality and in some series represents the leading cause of death. The annual cost of treating patients age > 65 years with pneumonia to be $4.8 billion, compared with $3.6 billion for those 85 years need help with bathing and 10% need help in using the toilet and transferring. The present of any or all of following identifies elderly persons at greatest risk for functional decline: pressure ulcer, cognitive impairment, functiona l impairment, and low level of social activity. The attack rate for pneumonia is highest among those in nursing homes. It is found that 33 of 1,000 nursing home residents per year required hospitalization for treatment of pneumonia, compared with 1.14 of 1,000 adults living in the community. Pneumonia is a major cause of morbidity and mortality worldwide. In the UK as a whole, pneumonia is responsible for over 10% of all deaths (66,581 deaths in 2001), the majority of which occur in the elderly. Community-acquired pneumonia (CAP) remains a common cause of morbidity. Because CAP also is a potentially fatal disease, even in previously healthy persons, early appropriate antibiotic treatment is vital. In Japan, pneumonia is the fourth leading cause of death, and from 57 to 70 persons per 100,000 populations died per year of this disease in the last decade. Community acquired pneumonia (CAP) is a leading infectious disease cause of death throughout the world, including Hong Kong, Pneumonia is the second most common infectious disease in Thailand. Whereas diarrhea is more common, pneumonia is associated with more fatalities. CAP remains the leading cause of death due to infectious diseases, with an annual incidence ranging 1.6-10.6 per 1,000 adult populations in Europe According to the Ministry of Health Malaysia (MOH), pneumonia is the 5th cause of death in Malaysia and the 4th cause of hospitalization. A prospective observational study by Jae et al (2007) of 955 cases of adult CAP in 14 hospitals in eight Asian countries found that the overall 30-day mortality rate was 7.3%. A prospective study by Liam CK et al (2001) of 127 cases of CAP in Malaysia found that the Mortality from CAP is more likely in patients with comorbidity and in those who are bacteraemic. A prospective study by LOH et al (2004) of 108 cases of adult CAP in urban-based university teaching hospital in Malaysia found that the mortality rate from CAP in hospital was 12%. 2.1.4 Syndromes of CAP The presence of various signs and symptoms and physical findings varies according to the age of the patients, therapy with antibiotics before presentation, and the severity of illness. Patients with pneumonia usually present with cough (>90%), dyspnea (66%), sputum production (66%% pleuritic chest pain (50%), and chills is present in 40-70% and rigor in 15%. However, a variety of nonrespiratory symptoms can also predominate in pneumonia cases, including fatigue (91%), anorexia (71%), sweating (69%), and nausea (41%). Metlay et al. (1997c) divided 1812 patients with CAP into four age groups: 18 through 44 years (43%), 45 through 64 years (25%), 65 through 74 years (17%), and 75 years or older (15%). For 17 of the 18 recorded symptoms there were significant decreases in reported prevalence with increasing age (p 37 °C at presentation. Crackles were present on auscultation in 80% of patients, and rhonchi in 34% to 47% (more common in the nursing home patients). About 25% had the physical findings of dullness to percussion, bronchial breathing, whispered pectoriloquy, and aegophony. Alteration in mental status was common. Marrie and coworkers (1989) reported confusion in 48% of the patients with nursing home-acquired pneumonia and in 30% of the other patients with CAP. Fine and colleagues (1998) define altered mental status as stupor, coma, or confusion representing an acute change from the usual state prior to presentation with pneumonia. This was present in 17.3% of the hospitalized patients. The decrease in symptoms with increasing age, tachypnea increased with increasing age (Metlay et al., 1997c). Thirty-six percent of 780 patients with CAP in the 18-44 year age group had tachypnea on admission versus 65% of the 280 patients who were = 75 years old. There were minimal differences in the proportion of patients with tachycardia and hyperthermia in the different age groups Pneumonia in the elderly are quite different from that in a younger population. These differences are due to age-related alterations in immunology, different epidemiology and bacteriology. It is important to remember that pneumonia in the elderly may report fewer respiratory signs and symptoms. The clinical presentation may be more subtle than in younger population, with more gradual onset, less frequent complaints of chill and rigors, and less fever. The classical finding of cough, fever, and dyspnea may be absent in over half of elderly patients8. Instead they may be manifest as delirium, a decline in f unctional status, weakness, anorexia, abdominal pain, or decrease general condition. The incidence of fever may decline with age, and the degree of fever appears lower in old population10. Tachypnea which respiration rate greater than 24-30 breaths per minute is noted more frequently in up to 69% of patients. Although rales are common and are noted in 78% of patients, signs of true consolidation are found in only 29%. Bacteremia, metastatic foci of infection and death are more frequent in older populations. As many elderly present with non-specific clinical symptoms and nonspecific functional decline that makes an accurate diagnosis difficult and may lead a life-threatening delay of diagnosis and therapy. Metlay et al. compared the prevalence of symptoms and signs of pneumonia in a cohort of 1812 patients and found that patients aged 65-74 years and over 75 years had 2.9 and 3.3 fewer symptoms, respectively, than those aged 18 through 44 years. The reduced prevalence of symptoms was most pronounced for symptoms related to febrile response (chills and sweats) and pain (chest, headache, and myalgia). These findings are consistent with those of Marrie et al. demonstrating reduced prevalence of non-respiratory symptoms among elderly patients. In a retrospective chart review by Johnson et al., the presence of dementia seemed to account for non-specific symptoms. However the sample size of the study was small and precluded a multivariable analysis. Roghmann et al found a significant inverse correlation between age and initial temperature in 320 older patients hospitalized for pneumonia. Evidence therefore does exist for a less distinct presentation of nonrespiratory symptoms and signs of pneumonia in the elderly. 2.1.5 Radiographic findings in CAP Radiographic changes usually cannot be used to distinguish bacterial from nonbacterial pneumonia, but they are often important for diagnosis of CAP, evaluating the severity of illness, determining the need for diagnostic studies, and selecting antibiotic agents. A chest radiograph usually shows lobar or segmental opacification in bacterial pneumonias and in the majority of atypical infections. Patchy peribronchial shadowing or more diffuse nodular or ground-glass opacification is seen less commonly, particularly in viral and atypical infections. The lower lobes are most commonly affected in all types of pneumonia. Small pleural effusions can be detected in about one-quarter of cases. Multilobar pneumonia is a feature of severe disease, and spread to other lobes despite appropriate antibiotics is seen in Legionella and M. pneumoniae infection. Hilar lymphadenopathy is unusual except in Mycoplasma pneumonia, particularly in children. Cavitation is uncommon but is a classic feature of S . aureus and S. pneumoniae infections. False negative results can be attributed to dehydration, evaluation during the first 24 hours, pneumonia due to Pneumocystis carinii, or pneumonia with profound neutropenia. 2.1.6 Etiology: More than 100 microorganisms have been identified so far as potential causative agents of CAP (Marrie 2001). They can be classified according to their biological characteristics as either bacteria, mycoplasma and other intracellular organisms, viruses, fungi and parasites. The most common causative agent of CAP is the bacteriumStreptococcus pneumoniae, which is implicated in 20% to 75% of cases of CAP (Marrie 2001) and about 66% of bacteremic pneumonia (Infectious Diseases Society of America 2000). Another causative bacterium is Haemophilus influenzae. So called â€Å"atypical† organisms have also been implicated as causal agents. These include Chlamydia pneumoniae, Mycoplasma pneumoniae and Legionella pneumophila (Marrie 2001). Influenza is the most common serio