Business Proposal Final for Thomas Money Service Essay Example for Free

Business Proposal Final for Thomas Money Service Essay The current financial status of Thomas Money Service Inc. needs attention to help improve its existing goods and services to overcome the challenges faced by the economy downturn. This proposal will address those issues effecting the profitability of Thomas Money Service Inc. and strategize affective ways to overcome those obstacles to return to profitability. â€Å"Thomas Money Service Inc. (TMS) has been in business since 1940† (University of Phoenix, 2012). The company started out granting small loans for consumer needs and evolved into offering business loans, business acquisition financing, and commercial real estate loans, (University of Phoenix, 2012). TMS expanded into equipment financing in 1946 under the subsidiary of Future Growth Inc. (FGI), (University of Phoenix, 2012). The venture in turn became very lucrative for TMS because of a huge demand in construction and forestry equipment after World War II (University of Phoenix, 2012). In 1951, FGI purchased an equipment manufacturing company building, selling, and financing their own building and forestry equipment and discontinued financing other equipment (University of Phoenix, 2012). For over 67 years it has been profitable and has stated in previous economic downturns that the company never had to lay off any of its workers, (University of Phoenix, 2012). However, in the current recession and after several natural disasters affecting forestry states, FGI profits declined last year by 30%. Home sales also declined, constructions slowed and caused FGI to repossess equipment and sell it at a discounted price. With the changing economic environment and profit loss Thomas Money Services Inc. has requested recommendations to help increase its revenue, determine its profit maximizing quantity, increase product differentiation, increase barriers to entry, and minimize cost of production. Market Structure and Elasticity of Demand Thomas Money Services Inc. operates in a monopolistic competition by offering products and services that can be differentiated and is very competitive with other sellers offering similar products for consumption. By creating an environment in which consumers looking to purchase equipment could receive financing and goods in a one stop shop has positioned TMS as leader in the market share in the construction industry prior to the recession. Because there are similar products available for consumers to obtain instead of FGI’s equipment, it has to differentiate its product and services as the best to have by nonpricing competition. The price elasticity of demand for Thomas Money Services Inc. from its original price of $1990.1 to its new price of $1732.0 shows the responsiveness of consumer to the quantity demanded of goods and services at its new demand of 182 million units from it its original demand of 123 million units shows that the PEoD is 3.70 resulting in TMS being very elastic. Although Thomas Money Services Inc. has not been a price taker but a price maker distinguishing it has a one stop shop for consumer’s construction equipment. The market has changed resulting in consumer finding alternatives to TMS goods and services decreasing revenue over the last year. â€Å"There are many domestic and international companies manufacturing construction and forestry equipment† (University of Phoenix, 2012). Because TMS offers elastic goods and services it has to continue to monitor the market to understand the demand. Recommendation Increase Revenue Increasing revenue is the objective for Thomas Money Services Inc. regardless of how the economy is doing. Because the market has declined in home sales, individual construction, and forestry equipment TMS should focus its marketing on hospital and nursing homes. According to University of Phoenix, not all sectors have been affected by the economic downturn hospital and nursing homes still have a high demand for new building (2012). These sectors are potential areas to increase revenue for TMS. Another area is in the price of equipment. To continue success in the marketplace the elasticity of demand plays a vital role. Currently, FGI has repossessed equipment and selling each unit at $1,732. From the demand chart below it will acquire revenue in the amount of $315,224 for the sale of 182 units. If FGI were to decrease the price to $1,634.3 per unit from the demand chart  below the demand will increase to 350 units sold, resulting in $572,005 in revenue. This will increase revenue b y $256,781 resulting in more profit to invest back into the company. Over the past years the data for demand is in millions. Table 1 Price Demand 1,990.1 123 1,732.0 182 1,634.3 350 1,252.0 380 732.1 400 622.3 456 Profit-Maximizing Quantity The monopolistic competitor maximizes profit by producing the output at which marginal revenue equals marginal cost (McConnell, Brue, Flynn, 2009). Marginal cost is the additional cost it would take to produce another unit of good or service. Marginal revenue is the additional revenue acquired from selling the additional unit. To reach profit-maximizing quantity Thomas Money Services will need to continue to increase output until its marginal revenue equals its marginal cost. Because TMS has been in business for more than 60 plus years it is currently operating in a long run curve where it earns a normal profit. Barriers to Entry Unfortunately, because Thomas Money Service Inc. operates in monopolistic competition there is relatively easy entry and exit into the market. When demand is high for construction and forestry equipment there will be surge of newer firms to enter the market because capital requirements are low. However, during this economic downturn many newer firms will exit because they will be unable to differentiate themselves from the longstanding branding and reputation that Thomas Money Services Inc. has had in the market. By making it more difficult to imitate TMS goods and service will result in an increase barrier to entry for newer competitors. Product  Differentiation In recent years, Thomas Money Service Inc. has decreased it advertisement revenue to having a commercial in the Super Bowl and a few other sporting events (University of Phoenix, 2012). In order to increase its product differentiation it will need to increase advertisement revenue to inform consumers of product differences, thus increase product branding and consumer loyalty. Since TMS operates in a monopolistic competition it has to advertise heavily to inform consumers of the benefits of its goods and services, especially in nursing home and construction magazines. When consumers prefer a specific product then within limits they will pay more to satisfy their preferences, thus making the product more inelastic to changes in the price in the long run (McConnell et al., 2009). Minimize Cost of Production While fixed costs have stay constant for various outputs of production for Thomas Money Services Inc. there are still ways to minimize cost. Installing proper equipment for processing and manufacturing the equipment and staying aware of the latest technology will help in cutting cost. By TMS shopping around for the best bargain in raw material and continually monitor variable cost to not exceed output of production. Combine project to offset prices for material for future projects Conclusion In conclusion, Thomas Money Service Inc. is a sound company that needs to adjust its strategy during this global recession to improve profits. This business proposal has addressed some of those issues to help increase its revenue, maximize profits, minimize cost, and differentiate it from its competitors. These recommendations are only few ways to overcome the challenges faced by TMS. Thomas Money Services Inc. will need to continue to monitor the market and their effectiveness to adjust to the ever changing-market. References McConnell, C. R., Brue, S. L., Flynn, S. M. (2009). Economics: Principles, problems, and policies (18th ed.). Boston, MA: McGraw-Hill Irwin. University of Phoenix. (2012). Thomas Money Service Inc. Scenario [Multimedia]. Retrieved from University of Phoenix, ECO/561 website.

Acute Exacerbation of Bronchial Asthma (AEBA) Case Study

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

Legalizing Marijuana in society

Legalizing Marijuana in society Legalizing Marijuana While most people recognize only the negative and harm that goes with marijuana use in society, there are several positive effects that are being ignored. In an essay written by Carl Sagan (1969), an advocator for legalizing marijuana, he states, â€Å" The illegality of cannabis (marijuana) is outrageous, an impediment to full utilization of a drug which helps produce the serenity and insight, sensitivity and fellowship so desperately needed in this increasingly mad and dangerous world.† Too many persons, marijuana users and even those who dont use the drug share similar sentiments. States like California have begun the quest for legalizing marijuana after many debates. Marijuana or cannabis as it is commonly called is a green or gray mixture of dried, shredded flowers and leaves of the hemp plant Cannabis sativa. It is smoked by rolling it in tobacco paper or putting it into a pipe. This drug is consumed by a great number of people around the world. There are over two hundred slang terms for marijuana including pot, herb, weed, boom, Mary Jane, ganger and chronic. The drug has always been considered an illicit drug ever since Harry Anslinger made false remarks at a hearing in 1937. However, many people cultivate it on a small or large scale for sale to the public and people in turn purchase it for use as a form of recreation and even medical reasons. Although from all accounts, many persons consider marijuana to be the least harmful drug among others, including alcohol and cigarettes, it is forbidden by law in many countries and parts of the United States of America. Some commonly committed drug crimes include possession of the drug, possession wit h the intent to sell, cultivation of the drug; drug trafficking, manufacture and distribution. Supporters of the criminalization of marijuana in the United States consider the use of the drug a felony and the laws governing marijuana are as rigid as those regulating cocaine or heroin. Users of the drug and even non-users request that laws be modified to alleviate the penalties related to its conviction when one is charged, or to have the drug legalized. It is proven that among all the crimes related to drug use, there are fewer crimes related to that of marijuana use. The Office of National Drug Committee in its report on the number of persons in jail for drug related crimes states that marijuana accounts for just 13 percent of all drug state offenders. From a broader prospective of the entire prison population, it was noted that marijuana was involved in the conviction of 2.7 percent of all state inmates. About 1.6 percent of the state prison population was held for offenses involving just marijuana while just 0.7 percent was incarcerated with marijuana possession as the only charge and 0.3 percent was first time offenders. It is claimed by the supporters of the legality of marijuana, that the drug stimulates crime in society. Yet, they ignore the simple fact that it is because of the strict but deteriorating law enforcements imposed on the use of the drug that encourages these simple crimes. An expert supports this in the following words, If marijuana users are no longer jailed for possession of the drug, lots of room will be opened up in our already overcrowded prison systems for more hardened offenders such as: murderers, rapists, child molesters and other violent criminals. The judicial system will no longer be burdened by having to trial cases involving marijuana. As a result, the police will be able to allocate more resources to solving more violent crimes. Since marijuana could therefore be purchased at any drug store after being legalized, violent crimes such as: robbery, drug warfare, contamination of drugs by other substances such as LSD, PCP and cocaine could quickly become a thing of the past (Saldevar, J., 2006). It is stunning to note the number of persons admitted in hospital emergency rooms due to the use of alcohol and cigarette (tobacco) use legal drugs. The following are statistics on alcohol vs. marijuana use. Records show that 100 thousand deaths annually are directly linked to acute alcohol poisoning while in 4,000 years of recorded history no one has died from marijuana overdose. It is also stated that alcohol causes physical and psychological dependences as well as temporary and permanent damages to all major organs of the body. Marijuana therefore, is a much less violent provoking substance than alcohol. It can be confirmed by hospital authorities that there are few or no marijuana related illness in their emergency rooms, while billions of dollars are spent on other illnesses, and this is worldwide. Therefore, it should not be maintained that this drug be considered a public threat. Marijuana legality will instigate cultivation and sale on small or large scale farms. The high demand for this drug will be met with governments gaining from taxes and licenses from the farmers. There will be no more drug-trafficking or smuggling of marijuana but instead shipping companies to profit from such activities. This multi-billion dollar industry will by no means fail the economy, once it is regulated. Currently, the governments are at a loss simply because it is already a growing industry that they are not gaining from. The revenues that will be derived from taxes can bring much needed relief from debts of the economy. Other segments of the country including education, health, and security among others, will have better programs as a result of sufficient or perhaps overflowing funds disbursed throughout the country. Employment will no longer be an issue once this new drug industry has been controlled. With such major investments waiting and the creation of employment certain, drug dealers or cultivators can now be equated to sales men or businessmen. Standard of living in the country or the world by extension will surely be thriving. Opponents of the legalization of marijuana should not deprive any county from such economic gain. While critics claim that marijuana should not be decriminalized, advocates maintain strongly that if the drug is regulated and taxed like other goods such as alcohol and tobacco, it will now become a product with major economic and medical benefits. Companies involved in the manufacture and packaging of the drug will adhere to all government and federal standards. This will include appropriate labels such as ingredients listings and disclaimers placed on packages so as to advice and warn users of its contents. These should be clearly and strategically placed on each package with supervised dosages recommended by federal and medical advisors. In that way there may be no case of misuse and the drug will be kept out of the reach of minors. When such health standards are put in place, the onus will be on the companies involved to adhere to regulations of the state. Legal drugs like alcohol and cigarettes can be out of reach for minors because they are sold in stores who need licenses. These stores have an incentive to sell only to adults in order to keep their license. There should be similar incentives for marijuana dealers. To protect our children we must give these marijuana dealers an invitation not to sell to them illegally. This cannot be done in a system of marijuana prohibition because we cannot take a license away if we did not give it out. To alleviate the many social and economic issues that stem from marijuana use, it is crucial that the drug be regulated and controlled. A freelance writer shares the same sentiments in an article by saying â€Å"If we take marijuana off the streets and regulate it, we will diminish organized crime problems† (Marshall, 2005). Advocators will agree that the negative effects caused by marijuana use are only increasing because of the laws against it. Such a controversial issue can be dealt with so easily with much to gain from. It is high time that young men on the streets became professional business men in the thriving industry that they are all passionate of, yet suppressed by law enforcements. It is the economys current state that has given people incentives to seek financial relief and recreation in marijuana use. It is now the economys turn to attain much more. The rewards from legalizing marijuana are unlimited. The end of all poverty and government debt lies in the hands o f those who keep this harmless drug prohibited. References Fox S., Armento P., Tvert M. (2009) Marijuana is safe: So why are we driving people to drink? White River Junction, VT: Chelsea Green. Katel P. (2009, June 12). Legalizing Marijuana. CQ Researcher, 19, 525-548. Retrieved February 01, 2010, from CQ Researcher Online http://library.cqpress.com/cqresearcher/ getpdf.php?file=cqr20090612C.pdf Klein J. (2009, April 02). Why legalizing marijuana makes sense. Time. Retrieved February 05, 2010, from http://www.time.com/time/nation/article/0,8599,1889021,00.html Kubby S. (2003). Why marijuana should be legal. New York: Thunders Mouth Press. Marshall P. (2005, February 11). Marijuana Laws. CQ Researcher, 15, 125-148. Retrieved February 01, 2010, from CQ Researcher Online http://library.cqpress.com/cqresearcher/ getpdf.php?file=cqr20050211C.pdf Moffat M. (n.d.). Should governments legalize and tax marijuana? About.com: Economics. Retrieved February 05, 2010, from http://economics.about.com/od/incometaxestaxcuts/a/marijuana.htm Sagan, C. (1969). Mr. X. In Marihuana reconsidered. (pp. 109-116). Cambridge, MA: Harvard University Saldevar, J. (2006, August 16). Marijuana: The simple logical benefits of legalization. Associated Content. Retrieved February 15, 2010, from http://www.assciatedcontent.com /article/50880/marijuana_the_simple_logical_benefits.html?cat=9

Museum Trip Essay examples -- Essays Papers

Museum Trip When this project was brought to my attention at the beginning of the semester I didn't know what to expect. I didn't know much about the history of art or any of the specific terms that are used in the art world. I have been to museums in the past but that was when I was in elementary school and they didn't teach us any of the specific terms that they used in the art world. On the handout that you gave the class you wrote questions that you though would be helpful for us to answer to succeed on this paper. The museum that I decided to go to was the National Gallery of Art in Washington D.C. In the following paper I will discuss what the museum looked like, the tour that I went on. What I thought of the tour, the pieces of art in the tour. How I felt while I was in the museum and the discovery that I found out about myself about the type of art that catches my attention. When I arrived at the National Gallery of Art, the outside structure of the building took my breath away. From outside looking at the museum its size just astonished me. The big tall granite columns and the granite steps reminded me of ancient Greek architecture. Once I made it up the marble staircase I finally arrived inside the museum. When I got inside the museum I had entered from the back and I had to walk to the information desk. On my way to the information desk I look around the museum to se if anything on that floor caught my eye. The statue in the middle of the museum...

The Last Full Measure :: essays research papers

The Last Full Measure is a vividly detailed account of the events that took place in the Civil War after the Battle of Gettysburg. In the novel, the author tells the story of the war after July of 1863 from several points of view. He uses three main characters to depict these points: Ulysses S. Grant, General of the U.S. Army, Robert E. Lee, General of the Confederate Army, and Joshua L. Chamberlain, a simple professor from Maine. The reader can gain a detailed understanding of the war by seeing it through Grant and Lee’s eyes. The reader can experience a more firsthand account of war by seeing it from Chamberlain’s point of view, who is not a professional solder. After reading this novel, the reader begins to realize what war actually means. To Lee, it is fighting for a way of life, while for Grant, it is the value of the Union and it’s dwindling future. The reader also realizes the hardships that come from war. For Lee, it would be not being able to see his family grow, while for Grant, it would be his struggle with alcoholism and depression. Also while reading the book, the reader is able to pick up two sides to almost every situation, the sides of Lee and Grant. In the foreword, Shaara states that his objective is to tell the reader the feelings of the men of the Civil War, which he achieves by using an immense collection of knowledge to probe into the lives of the soldiers. Shaara gives the audience an objective novel that shows the hardships in one of the greatest wars ever fought. Toward the end, Shaara takes a clear, anti-war stand. It is obvious that he realizes why wars are fought, but cannot understand why we have never learned from our mistakes. The novel is ended eloquently by showing the war’s effects on each of the main characters and what has become of them in the time after the war. Lee tries to make up lost time with his family, while Grant serves two terms as President and later enjoys retirement. Chamberlain was awarded the Congressional Medal of Honor and later became a governor. Both Lee and Grant eventually publish their memoirs at the end of the novel and look back on the war, which is told by Shaara to be a key event in The Last Full

Can We Reduce the Rate of Juvenile Crime and Violence? :: Argumentative Persuasive Essays

â€Å"Palm Beach County, Fla. -- On May 26, 2000, 13-year-old Nathaniel Brazill shot his teacher, Barry Grunow, with a .25 caliber handgun in school. Palm Beach County prosecutors tried Brazill as an adult for first degree murder. The jury found Brazill guilty of second-degree murder and the judge sentenced him to 28 years in an adult facility. After his release, Brazill will face two years of house arrest and five years of probation.† (Klug) Does this sentence seem too harsh, or perhaps too lenient? Without knowing all of the details involved in the case, it may be harder to decide what would be the best thing to do with 13-year-old Brazill. What specific details would a person need to know in order to sentence him properly? Has he ever done this before? What were his motives? Is he from a rough neighborhood, living in a bad family situation? Maybe all of these things don’t matter in determining Brazill’s sentence, and he should just be punished according to his crime. If you’re having a hard time deciding, you’re not alone. Since the juvenile court’s introduction in 1899, there have been debates over whether or not the court is effective in treating juveniles. Brazill’s case demonstrates the view that the juvenile court is not working, or is not sufficient to deal with cases as serious as Brazill’s. This is evident in the fact that he was sent to adult court as a 13-year-old as opposed to being tried in the juvenile court. The recent shift toward trying more juveniles as adults is a plain indicator that the juvenile justice system is not working. No one will disagree with that. However, people will disagree on what the system is supposed to be doing in the first place, and how we as a nation should go about fixing it. There are many different approaches to how juveniles should be dealt with, and each approach is extremely complex. One of the main factors that causes the complexity is that with each approach comes certain doctrines on the differences between juveniles and adults.

The Early English Colonies In America

Early English colonies in America hardly resembled the union of men and women that would later fight against England and build a new country. In fact, until the mid-eighteenth century, most English colonists had very little, if anything to do with the settlers in neighboring colonies. They heard news of Indian wars and other noteworthy events, not from the colony itself, but from England. The colonies in the New World appeared completely different and the prospect of any unity between them seemed impossible. The colonies in New England and the Chesapeake exemplify the many differences in the culture and lifestyles of the settlers, created mainly because of the fact that their founding fathers had held separate intentions when they came to the New World. The New England and Chesapeake colonies were both settled by immigrants from England, the New England colonies being founded by the English from East Anglia, an area in eastern England. Though this was an area thriving with small towns that they had generally liked, they decided to flee England due to religious persecution. Hundreds of families, men, women and their children, came in search of a New World where they could practice their beliefs freely. They founded colonies such as Connecticut, Massachusetts, New Hampshire, and Rhode Island as model Christian societies. Their cities upon the hills were guides, the lanterns, for those lost in the darkness of humanity, as John Winthrop meant by his famous statement. They formed a society of strict religious participation, actually very much resembling their homeland. In the beginning, many called themselves Puritans, and kept things very simple and plain, concentrating on what was important to them. They used the community to achieve their goals, building new towns and enjoying the social aspect of their religion. At the same time, they were committed to remain working hard to keep their community productive. They believed the â€Å"idle hands† were the devil†s workshops. An issue that really defined a split between the societies was the slavery conflict. The northerners in New England held true to their belief that every man shall be equal and no one should be enslaved, while the southerners in the Chesapeake area strongly believed in the use of slavery. At the same time the New Englanders worked to help end slavery by preaching to others about the injustices, they worked diligently to make education in their society strong. Most people in the towns were literate so that they could read their Bibles and study them in detail with their friends and family. Some colonists were artisans or merchants. Others were small-town farmers, making sure that every member of the community had a reasonable share of God†s land. The northern colonies were renowned for being rich in furs, timber and fish. They were especially noted for developing into a very successful trading region. The New England colonies made up the middle class society whose focal points were family, education and religion. The society remained non-capitalistic, yet still buzzed with much activity. On the other hand, the Chesapeake region had a â€Å"cash crop† get rich quickly mentality. This aristocratic region consisted of Virginia and Maryland, two colonies that seemed to be exceedingly materialistic. Evidently, their lives were based more on their liquid assets than on God or family. The Englanders who saw the opportunity to take advantage of the popularity of a brand new crop they had discovered settled the Chesapeake area. These â€Å"gold diggers† were mainly upper-class men of wealthy families aspiring towards coming to the New World to create a large profit for themselves. These colonists were not fleeing England seeking religious or social freedom, but clearly only to add more wealth to their names. Tobacco soon became the primary crop seen growing on almost every one of these wealthy men†s plantations, which created tremendous amounts of money to add to their fortunes. Of course almost every plantation had African slaves working on the land. These colossal estates cam! e to depend on their slaves to run their farms and slavery became a common, yet feared, way of life for many Africans. Unfortunately for these Chesapeake colonies, due to swampy land in much of the area, towns were not part of the landscape or lifestyle as they were in the north. This area was a place of fierce competition with a very minute sense of community, as opposed to the thriving northern colonies surrounded with warm and inviting community towns. The strong focus on family, education or religion was not a main highlight in the lives of Chesapeake colonists, except in Maryland, where the Calvert family did indeed form a haven for Catholics. These two regions of the New England colonies and the Chesapeake colonies did in truth share the common fact that their settlers were all of English origin. Of course when they first set sail, even before they reached the New World, they began to separate into two distinctly different societies already. The clearly evident reason is because these â€Å"pilgrims† came to the New World each pursuing something different. The New England settlers were longing to find a more suitable land of opportunity where they could better their lives and gain religious freedom. They wanted very much to create a society where they could focus on their family, religion and education. Where as the Chesapeake settlers, they were clearly hoping to â€Å"strike gold† in the New World. Many hoped they could improve their social status even more by gaining large profits from growing and selling such items as tobacco. The New England colonists came and made a quite simple society and the Chesapeake colonists created a more aristocratic society. Their society seemed to care more about their wealth and power more than anything, where as the New England society grew to be one with important focus†. These two regions may have shared that same origin and spoken the same English language, but they rarely â€Å"spoke of similar things. † Because of this culture barrier, a separated north and south was created, causing two distinctly different societies to evolve.