Honour and Loyalty in “to Kill a Mockingbird”

Throughout the novel â€Å"To Kill a Mockingbird†, Harper Lee presented many examples to the reader regarding honour and loyalty. Harper developed the traits of honour and loyalty through her portrayal of the characters; Atticus Finch, Arthur â€Å"Boo† Radley, and Calpurnia. Atticus Finch was a distinguished symbol of honour and loyalty. He was a man who honoured his well-kept reputation in the town of Macomb and stayed loyal to the people close to him. One example of Atticus’ honourable character was when Bob Ewell committed the fallacious act of spitting in his face. Atticus kept full composure, and walked away, instead of fighting with Bob. This showed how Atticus did not want his reputation in Macomb to diminish. He explained to Jem that he had â€Å"destroyed his (Bob Ewells’) last shred of credibility at that trial† (Harper Lee, 1960, p. 218). He also explained to Jem how â€Å"spitting in my face and threatening me saved Mayella Ewell one extra beating† (Harper Lee, 1960, p. 218) . This demonstrated honour in Atticus as he cared for Mayella, putting aside how harshly she had treated Atticus and Tom Robinson in the past. Loyalty was displayed when Atticus made the vital decision to take on the Tom Robinson case. He fully defended Tom no matter what others would say. Atticus took the case for another reason; he believed in equality and thought that black and white people were to be treated equally. Atticus honoured Ms. Dubose and showed respect by speaking kindly of her all the time. Although the children told Atticus how she treated them, he still greeted Ms. Dubose; â€Å"good evening Ms. Dubose! You look like a picture this evening. † (Harper Lee, 1960, P. 109). It took great honour for Atticus to be this respectful towards Ms. Dubose, considering how disrespectfully she treated Jem and Scout. Read also  How Powerful Do You Find Atticus Finch’s Closing Speech? Another character who showed honour and loyalty in â€Å"To a Kill a Mockingbird† was Arthur â€Å"Boo† Radley. During the initial stages of the novel, Boo kept leaving little things in the tree for the children to take. He was acting honourable and trying to befriend them, as they acted seemed of him. Additionally, Boo put a blanket around Scout during the fire. At first, Scout thought it was Jem who had put the blanket around her, but when she found out it was Boo, she was surprised, and started to think differently of him. Jem told Scout that she was â€Å"so busy looking at the fire, she didn’t now it when he put the blanket around her† (Harper Lee, 1960, p. 72). Arthur Radley was honourable towards the Finch family by killing Bob Ewell. Bob had caused many problems for the Finch family, and was the cause of Tom Robinson’s death, which followed after the court case. His actions proved as justice for the Tom Robinson Case, as well as for the assa ult on the children (which left Jem with a broken arm). Lastly, Calpurnia was also a significant character in this novel who illustrated honour and loyalty. She took Jem and Scout to an African American church. The children were not welcomed warmly. Calpurnia stayed loyal to the children, and fully defended them when everyone else wanted them out. A woman from the church was displeased with the fact that Calpurnia had brought these children to their church. Immediately, Calpurnia backed the children, saying that there was absolutely no difference between white or black people, so the children were to have every right to stay in the church. As a â€Å"mother figure†, Calpurnia was a very good influence on both of the children, she taught them how to be honourable to people, and to respect others. When Walter Cunningham went over to the Finch’s for supper, Scout made a comment on the way Walter was pouring syrup all over his dinner. Calpurnia took Scout straight to the kitchen and told her that â€Å"Yo‘ folks might be better’n the Cunningham’s but it don’t count for nothin’ the way you’re disgracin‘ ’em† (Harper Lee, 1960, p. 31). After the stern vituperation, Scout went back to the table and was more respectful towards Walter. Calpurnia had also worked with the Finch family for much of her life, which showed her loyalty for them, and the respect she had gained from Atticus. After Calpurnia was told to leave the Finch home, Atticus strongly defended her by telling Alexandra that she was a â€Å"faithful member of the family and she’d (Alexandra) would have to accept things the way they were. † (Harper Lee, 1960, p. 147) In conclusion, Atticus Finch, Boo Radley, and Calpurnia were three significant characters who clearly demonstrated honour and loyalty throughout â€Å"How to Kill a Mockingbird†. They also played important roles in helping the children to become loyal and honourable.

View of Love and Sex in “Wuthering Heights”

â€Å"Wuthering Heights† accurately reflects many of the attitudes associated with love and sex in the Victorian Era. With reference to appropriately selected parts of the novel and relevant external, contextual information on Victorian attitudes to love and sex, give your response to the above view. The Victorian era when â€Å"Wuthering Heights† was written and first published was a time when love and romance and true emotion were the antithesis of reasons to marry. Sexual love was frowned upon greatly and no woman should ever have had sex outside of marriage. Sex was something that was solely for procreating and nothing else. Although, it was considered that a man could not control his animal instincts and so if he had sex outside of marriage of ever cheated on his wife, it would not damage his social desirability or impair his reputation on society. Marriage in Victorian times was for a place in high society and financial stability and children. This is shown in Wuthering Heights when Cathy marries Edgar Linton instead of Heathcliff because she knows it would degrade her to marry Heathcliff. This is also very common in Victorian times; people were not to marry below their own class. They would marry above or in the same class as themselves. Victorian literature always focused on idealised representation of people who use work hard, perseverance and love to win out in the end. Good deeds will always be rewarded and wrongdoers will be punished. All novels were very moralistic and usually had a good social message or comment on society, for example, Oliver Twist. Victorian novels tended to be melodramatic, including features such as pathetic fallacy, exaggerated emotions, extreme passion and unrealistic characters. Victorian novels are also very long, with lots of characters, plots and intertwining sub plots. Wuthering Heights is very different from this in that it is set in a very isolated scene with a small number of characters. The relationship between Cathy and Heathcliff completely defies everything that was typical about a Victorian real-life relationship and the relationships in novels. They share such extreme passion and love for each other that shocked everyone who read in and the contemporary critics such as H. F. Chorley, who said the novel â€Å"was disagreeable and seem to affect painful and exceptional subjects. † The Atlas also said that each chapter â€Å"seems to affect painful and exceptional subjects†. People didn’t understand how a woman could understand and write so convincingly about something that she couldn’t possibly have experienced. Victorians were not allowed to spend any time alone with their partners until their engagement was official and even then they were only allowed to hold hands and were not to be alone together after midnight. Cathy and Heathcliff had grown up together and slept together as children and spent a lot of time alone in the moors and this was not accepted easily. Wild passion is a major theme in Wuthering Heights. The relationship between Cathy and Heathcliff is haunting and powerful and from the very start we can see the intensity of their feeling towards each other. There are various parts of this novel which make us certain that nothing could ever come between Cathy and Heathcliff. Cathy confesses her love for Heathcliff so passionately and sincerely, â€Å"I love him, not because he’s handsome, Nelly, but because whatever souls are made of his and mine are the same. † The reference to the souls shows that it is not physically love that they share but, even after death, their souls will still be as one and together. Nelly, I am Heathcliff,† they are the same person and even when Cathy dies she knows she will still be alive through Heathcliff. It is not physical, sexual desire that causes them to need each other, even though Cathy’s death destroys Heathcliff, but kind of a spiritual force which connects them together. This is also showed when Heathcliff says  "Oh, God! It is unutterable! I cannot live without my life! I cannot live without my soul! † There are also other love relationships to explore throughout Wuthering Heights, one of them being the relationship of Edgar Linton and Cathy. The relationship between the two is the exact opposite of that of Cathy and Heathcliff. Their marriage is of convenience to Cathy although Linton does adore Cathy very much. Cathy has typical reason to marry Edgar such as, â€Å"he’s handsome and pleasant to be with †¦ he is young and cheerful †¦ he will be rich, and I shall be the greatest woman of the neighbourhood. † At the time of the novel these were all perfectly acceptable reasons for wanting to marry someone and these were not things the Heathcliff could provide Cathy with. Cathy explains her conflicting emotions between Edgar and Heathcliff as, â€Å"moonbeam from lightning, or frost form fire. † Cathy and Edgar marriage is very Victorian, very typical and very acceptable, love was not a necessity. Although we can tell Edgar loves Cathy and that it means something in its own way, it is still only a mere affair next to the wild, uncontrolled passion of Cathy and Heathcliff. All of this leads me to say, no, Wuthering Heights does not reflect the attitudes of love and sex in Victorian times. Cathy and Edgars relationship defiantly does but it is not the main relationship in the novel and even so, Cathy, as a married woman still loves Heathcliff and spends time alone with him and this is not typical of a Victorian relationship as women practically belonged to their husbands and this is not the case here. This novel is completely different from other novels of its time as it doesn’t have a moral, the good are not rewarded and the bad are not punished and there was no social message, it has no defined place in literature.

Analysis of ICT market in UK Essay Example | Topics and Well Written Essays - 1750 words

Analysis of ICT market in UK - Essay Example The Vodafone and Telefonica-O2 were newly licensed in the same Conservative government. It produced the far-reaching variations in ICT sector of UK. It stimulated the competition and enabled the mobile manufacturing companies to make the innovative products. During the same time, Asian and Eastern Europe countries had become capable to compete in manufacturing the electronic products in market. In reply to this electronic growth, ICT sector of UK concentrated on the software services. ICT sector was much focused to develop the new software instead of making the new hardware. ICT industry in UK is concentrated with most famous fifty companies of the world. On other hands, there are 95000 small level firms. The smaller firms are micro-business with fewer than ten employees. Software design, IT management, IT consultancy, IT reselling and distribution are key activities of ICT market in UK. This paper is focused upon the market analysis of ICT market in United Kingdom. ICT market analysis in the perspective of sub-sectors particularly education and why small medium enterprises (SMEs) are slower in full adoption of ICT in UK? Along with this impacts of ICT on education sector of UK has been also analyzed. Literature review is aimed to summarize ICT market analysis in UK. Market analysis allows seeing the technology impacts on different sectors varying from education to SMEs for their businesses. Review will help to identify the areas, where ICT has impacted positively and investigate the areas which are less or negatively impacted. The ICT market as a whole in UK is most attractive for foreign companies to invest in ICT goods and services. UK’s legal framework is supportive for business in ICT sector. Increased appetite of consumers in UK for technology supports the build up and growth of UK’s marketplace (UK Trade & Investment, 2009). In a report   Middleton (2014) identified that a strong link existed

Competitive Analysis Essay Example | Topics and Well Written Essays - 1000 words - 1

Competitive Analysis - Essay Example Macintosh products are hip, edgy, associated with quality, and innovative. Smartphones are defined against the IPhone and tablet computing against the IPad. Millions of consumers wait in anticipation for the next Mac release. But there are cracks in their armor. â€Å"The collective Apple community has been so intoxicated by the iPod, the success of the iTunes Store, MacBook sales, and excellent Mac OS X security that no one is reflecting on the areas where Apple is vulnerable. Perhaps it is unpleasant to think about, but neither do we want to live in a state of denial† (Martallero, 2006). Mac has traditionally had weaknesses in the arena of high performance computing. They are not associated with gaming computing in any way and they hold a small chunk of the personal computer market. They also don't any foothold in the corporate computer market. This is irrelevant to the Samsung Tab's success, of course. They also have weaknesses in the enterprise market. The music market is a very big weakness: Despite the IPod helping save the music industry from serious problems, they still have a goal, to sell music. Samsung could do what the Zune tried to and failed: Make a serious competitor to Macintosh in the music department by making strategic alliances. It is in the music industry's interest not to have to deal with a monopoly power in the field of MP3s, particularly the ITunes store. That having been said, this does mean competing for a share of a pie that piracy is always in danger of shrinking. The entertainment industry is similar: They want to sell electronic versions of their movies. If Samsung gets in on the ground floor in this regard, they will be successful. Dell's new tablet announcement that got leaked is also a serious threat (Cush, 2011). â€Å"The already available Dell Streak and Dell Streak 7 are listed, and according to the leaked "Tablet Roadmap," they will be joined in April by the Gallo Honeycomb tablet. The Opus One and Silver Oak Honey comb tablets will follow in early 2012, just in time for CES† (Cush, 2011). Dell has two major advantages. First: They are the big dogs in the field of personal computing. When it comes to building and selling PCs, laptops and notebooks, they are associated with great success. Millions of customers have a Dell PC with an Intel processor: The two are associated with reliability and value. Samsung, on the other hand, is mostly considered to be a maker of TVs, screens, other ancillary products. It seems likely that, faced with the choice between what looks like a Dell computer that just happens to be a tablet or Samsung's new experiment, many people will choose Dell out of sheer brand name recognition. Second: They hit the ground earlier. They launched already. Samsung is a bit late. But the real competition that Samsung has is the PC and other electronic products. The IPad is competing in the tablet market, which is a small market, against people who already are centered on home or laptop computing. If someone has a desktop computer, they are far less likely to think a tablet computer is a worthwhile investment, but might think it's interesting or want mobile computing. If they already have a laptop, the IPad's arguments for existence as a product become far slimmer indeed. Even some video game systems like the DS, PSP, PS3, Wii and XBox 360 are in a real way competition for the Tab. These systems have so many utilities in terms of playing movies, music and doing other

Choose one Essay Example | Topics and Well Written Essays - 500 words - 3

Choose one - Essay Example Parents should show their children the value of improving the innate talents. Children have different mindsets and temperaments since some are shy while other display self-confidence. According to the ethical principle of common good, parents should allow their children to attain both spiritual and human flourishing by encouraging the development of innate talents (Gill 98). The society should also allow each human being to fulfill his vocation by offering an enabling environment for the development of talents. For instance, Josh Waitskin started playing chess at six years and won the first championships at age of age. Josh followed his innate talent and his learning process. Josh’s mother never discouraged his child to start playing Chess despite his young age. According to Josh, parents should encourage children to express their own unique individual personality. Parents have the ethical duty to instill confidence and assist their children develop the talents. According to t he principle of distributive justice, every human being in the society should be accorded human dignity and respect notwithstanding his quality of judgments. Parents should allow their children the opportunity to learn from their own experiences (Gill 110). Sadly, Josh Waitzkin lost his passion for Chess at 19 years due to pressure to meet other people’s expectations. Josh advises school authorities and parents to encourage children to listen to their â€Å"own natural voice and help the kids to develop their innate gifts (Josh, Waitzkin YouTube video)† On the other hand, opponents assert that parents should control the choices of their children regarding the development of innate talents. They argue that children have no ability to make informed decisions thus lack the right to choice. Parents should make decisions on the choices of their children regarding the development of innate gifts. Parents should set high and realistic goals for their

The Fukushima Daiichi disaster and the future implications for Research Paper

The Fukushima Daiichi disaster and the future implications for building new nuclear power plants in the United States - Research Paper Example The calamity was observed to have taken place in the eastern coast, Tohoku in Japan. The severe tremors of the quake were experienced at Fukushima as well (American Nuclear Society, 2012). The above mentioned catastrophe was later found to have significantly affected the ‘nuclear power station’ or rather the nuclear plant that is situated at Fukushima Daiichi in Japan. This disaster was believed to have triggered the most far-reaching ejection of radioactivity in contrast to the Chernobyl mishap that took place in 1986. This particular radioactivity release was considered to be even shoddier than the case or disaster of Three Mile Island that took place in 1979 in the United States. However, the occurrence of Fukushima Daiichi was considered to differ from the stated incidents of Chernobyl and Three Mile Island as the devastation that occurred at Fukushima was learnt to be triggered owing to natural tragedies which was a massive earthquake chased by tsunami. The discharg e of the radioactive gases was regarded as a consequence of the natural disaster rather than any malfunction with regard to the equipments and even ruled out any chances of human faults. The tsunami was measured to have ruptured the systems that helped in providing backup power and which were required for the reason of cooling down the reactors that were present in the definite plant. The breakdowns of the backup systems as a result made a large number of those reactors go through hydrogen explosions, fuel melting and ultimately radioactive releases (Holt, Campbell, & Nikitin, 2012). The paper will intend to focus on the present situation of the mishap that occurred at Fukushima Daiichi along with providing an insight into the various policies or stands taken by the US after this incident. The Accident at Fukushima Daiichi in Japan The earthquake that took place in March, 2011 in the eastern coast of the island Honshu in Japan resulted in initiating a mechanical shutdown of around e leven nuclear plants out of fifty five. Majority of the shutdowns were found to have carried on without any kind of further events. However, the Fukushima and the Onagwa nuclear plants were found to be the ones that were closely located towards the epicenter owing to which severe damages were suffered by those plants. The plant at Fukushima Daiichi, as a result of the earthquake, accompanied with the tsunami experienced hydrogen outbursts and grave damages in relation to nuclear fuel which triggered the discharge of a noteworthy quantity of radioactive elements in the surrounding environment (Holt, Campbell, & Nikitin, 2012). The contamination of the surrounding environment, with the radioactive elements that originated from the plants, compelled the moving out of communities from the adjacent or the neighboring areas till 25 miles. The forceful move out of the communities resulted in disturbing the regular life of around 100,000 residents, majority of whom were believed to remain b anned from accessing their respective homes for an indefinite period. The evacuation activities made in this context are considered to have checked the degree of radiation exposure with regard to the concerned population from surpassing the Japanese authoritarian boundaries in majority of the incidences. However, the consequences of the exposure to the radioactive gases with regard to the residents were measured not to be quite grave. Future deaths as well as

Explain what the current situation is, what problems are in evidence Essay

Explain what the current situation is, what problems are in evidence and how those problems should be addressed - Essay Example There are different inventory models and policies for single supplier and multiple suppliers and allied benefits as well as drawbacks for each of them which would be evaluated in the report. Certain recommendations related to purchasing and inventory functions would also be rendered so that the existing difficulties can be alleviated by a considerable extent. Table of Contents Executive Summary 2 Introduction 4 Conclusion 13 References 14 Introduction Inventory is defined as the stock of materials or any other item that is being used by an organisation. It is further defined as the idle resource of any kind that has a considerable economic value. It has been observed that inventories are supervised in order to meet the future demands of the process of production. The term ‘inventory management’ is regarded as the process of maintaining the finished goods, and the semi-finished raw materials of companies or any other business. It has been learnt that efficiently managed i nventory would result in an increase in the revenue by cutting down the cost of the company. The process of inventory management commences as soon as the company starts its production and orders the required raw materials for the same. In case of a retailer, the process commences as soon as it places an order to the wholesaler. ... faces certain difficulties in purchasing and managing inventories for the parts and materials of diverse brands for providing services to the customers. The Chief Executive Officer (CEO) of the company is concerned about the future requirements of vehicles parts and materials to meet the ever-increasing needs and demands of the customers. Based on the understanding of the case study, the report intends to illustrate the differences in inventory policies when there are multiple suppliers involved. The report would further discuss about the weaknesses in the current inventory management practices of Lancaster Motor Group and recommend appropriate measures to tackle the difficulties particularly related to purchasing and inventory function. Q.1. How Might Purchasing And Inventory Management Policies And Procedures Differ Because The Dealerships Purchase Different Types Of Service Parts And Materials (E.G. Lubricants Versus Genuine Parts) From Different Types Of Suppliers? Galena Markovi c was quite concerned about the future prospect of the company. She did not want the company to face the problem that other companies are facing with regard to managing the purchase of varied parts of automobiles in future. As it has been noticed that the company had a good reputation in terms of the deliverance of services, she became more concerned about its operations. For these reasons, she began thinking regarding supply chain and inventory management to resolve a bit of her concerns and pressures. However, as she is selling the product of four companies, she would have to buy the parts from various suppliers (i.e. multiple suppliers). In this regard, she would need to follow inventory policies different from that of the usual inventory management policy of single supplier. When a

SQL database paper Essay Example | Topics and Well Written Essays - 750 words

SQL database paper - Essay Example The customerID field is a unique area because each customer will have their unique customerID thus the reason for its use as the primary key. The newly introduced tables allow us to have several booked tours associated with a customer thus increasing the flexibility of the system. It also reduces the storage space required. The tour1NF tables are added to allow customers to make several orders (â€Å"Informix Guide†, 1998). A table that keeps tours sold and tour customer data, holds, address, customer name, city, zip code state, tour(s) selected, total amount paid and the number of persons in the tour. Therefore, the structure will be able to show the customer in case he/she books more than once. Data modelling refers the process of examining data-oriented structures, in that you single out entity types into which attributes are assigned to. The conceptual model can be used to represent the data above. To make the table2NF compliant we introduce the customerID field as the primary key of the customer table and the foreign key of the newly created table in 1NF tours selected table. This makes the table 2NF compliant. Using the salesperson table that was described earlier the most appropriate trigger would be a Data Modelling Language (DML) trigger. The trigger is initiated every moment the salesperson sales a tour. In the new data model the customer information is subsidiary to sales information, the trigger is identified as â€Å"for each statement type† and is an additional data set for the salesperson each time the tour booking triggers the event. Using the salesperson table described the appropriate trigger would be a Data Manipulation Language (DML) trigger and would be initiated each time a tour operator sells a new tour. Under the new structure in which the client information is subordinate to sales information, this trigger would be identified as â€Å"for each statement type† and would add data set for the

Animal Rights Essay Example | Topics and Well Written Essays - 750 words - 1

Animal Rights - Essay Example Torturing a cat or setting it on the fire by the way of childish prank is one of the key examples of wrongdoing in the literature of philosophy. It is true that all breathing animals have morale rights like human beings. They breathe and live like us. Most importantly God created the animals. Therefore, it can be stated that non-human animals also have the basic rights similar to the human beings. It is true that all the non-human animals play effective role in the society. Therefore, it is the responsibility of human beings to give proper value to these non-human animals. The non-human animals also can feel their joy, pain and sorrow similar to the human beings. Therefore, it can be stated that it is the responsibility of the human beings to be kind to the non-human animals. Question 2 It will be unsocial and unethical if the human beings treat the non-human animals as the â€Å"ends in themselves†. The non-human animals have the fundamental rights to live like the human bein gs. All the non-human animals have effective value, contribution and responsibility in the ecology (Regan 13). It is necessary to have all kinds of animals in the society as it helps to maintain the ecological balance. The human beings achieve huge benefits and advantages from these non-human animals. The non-human animals have important contribution in agricultural and industrial sectors. Therefore, animals have the right to die or get injured if they harm the human beings. Similarly, it is the right of the innocent non-human animals to live without fear in the society. Human beings should not hurt or kill the non-human animals considering the law of humanity. This law of humanity does not allow the human beings to torture or kill a non human animal. The human beings are mentally strong than these non-human animals. Human beings are known as social animals. They are more intelligent than the non human animals. It is true that, the non-human animals cannot think like the human being s, but they can feel and respond to external factors in similar way. Therefore, it can be stated that, human beings should not treat the non human animals as ends in themselves as it will violate the law of nature. Cows, dogs, cats and birds are the domestic animals. They give unconditional love to human beings. Similarly it is the responsibility of human beings to take care of their lives and needs. They cannot communicate with the human beings through their voice. But it is true that they can feel things in similar way. These non-human animals are called obedient animals. They are loyal to the owners. Therefore, the attitude of human beings towards these non human animals should be changed. In terms of fundamental rights of non-human animals and moral ethics, it can be stated that killing or torturing of animals should be stopped as it can hamper the ecological balance. Question 3 According to Kant’s argument, the non-human animals have souls as they are able to move. It is an ontological distinction between the non-human animals and matters. The non-human animals are not just matters or mere machines. The animals do have souls as everything in the nature is either animate or inanimate. Moreover, the non-human animal can feel the inner aspects, such as pain, joy and sorrow. Therefore, it can be stated that the non-human animals are an animated matter lack of inner spontaneity principle. According to the ethical view of Kant, the human beings have the ethical right to injure or kill the non human animals. Moreover, he argued that the non human animals should be killed without pain and quickly. This action should not be for the sake of entertainment and sport. According to Kant, the human beings should not perform the painful experiments on these non human a

Philosophy of business law Essay Example | Topics and Well Written Essays - 250 words

Philosophy of business law - Essay Example On the other hand, in contra of those arguments are that privacy isn't an issue where legal status is concerned. Searches are not unreasonable to the police if they turn up something illegal. Unwarranted searches can be legal with reasonable suspicion that something illegal is taking place. Profiling is just a way for the police to keep abreast of developing situations. Rights can be violated, however, to stop the law from being broken, which is what the argument might be. The Constitutional basis for objections filed by the state AG's would be that not everyone wants or needs health care. This violates a person's right to freedom as guaranteed by the First Amendment. Their liberty is in jeopardy as well. If the U.S. were to be represented, their best defense would be that every American needs health care because it is a Constitutionally guaranteed right. The Supreme Court should rule that health care is mandatory, and that without it, people would be in dire straights. The client in the case where he is selling wood does not have a sound basis for overturning the DNR regulation.

Poem Comparison Essay Example for Free

Poem Comparison Essay All four poems that I read are related in their purposes and goals; however, they are also very different. Lucinda Matlock by Edward Lee Masters, Chicago by Carl Sandburg, Richard Cory by Edwin Arlington Robinson, and We Wear the Mask by Paul Laurence Dunbar are all about the joys and sorrows of life. How we look at life makes life good or bad. Lucinda Matlock is a story of a woman, who, by some standards, would have a life that we consider a mediocre. However, the narrator of the poem says that it was a good life and that life can only be truly appreciated if it is taken from you. Chicago by Carl Sandburg is the most closely related poems to Lucinda Matlock. In the poem, the people of this city are dirty, evil, and happy. The people are not saying to themselves, Well, my life is horrible because this is where I live and this is my underpaying job. They are laughing and joyous because they have life. Chicago is unlike Lucinda Matlock because Carl Sandburgs depiction of life in Chicago is so much more cynical than that of Masters more optimistic characterization and depiction of life in the world. Richard Cory is a poem about an aristocratic man that under- appreciates life, and, as a result commits suicide. The narrator talks about how envious he/she is of Richard Cory. Only in the very end do they mention the fact that he is actually a very sad man. This poem is a representation of the front that some people put up to hide their inner selves due to embarrassment or many other feeling of despair. Finally, we read We Wear the Mask by Paul Laurence Dunbar. This is very similar to Richard Cory in its message. The message is again that there are some who sometimes cloister their inner selves behind a barrier of a fake personality. In the poem, Dunbar writes: Nay, let them only see us while/ We wear the mask/ We smile, but oh great  Christ, our cries/ To Thee from tortured souls arise. The second part of the quotation says that they have tortured souls. They smile to hide their pain and they cry to Christ for help. All of the poems share the common theme that life is what you make it and that people often hide their true identity behind a false one (As shown in Richard Cory, We Wear the Mask, and Chicago). Though the final two poems mentioned have more in common with each other than they do with the first couple poems that were talked about in class, all of the poems are similar in their ultimate subject matter.

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

Japanese Airlines (JAL) Human Resource Management Practices

Japanese Airlines (JAL) Human Resource Management Practices The world we live in is constantly faced with many new challenges that must overcome to survive in which business world is one of them. Changes in the world have affected many companies and industrial activities to develop and able to adapt in various kind of nature (Kearns, 2010). The most effectively modified to profit in the business world would be the approaching to human resource sector. For the past decades, human work force have been using like an operating machines, working hard and harsh. But in the present world, human work force can be call the most valuable assets for the business world, presenting as a company core competency and the force that would drive an organization to archives goals (Pate Beaumont, 2006). Management in human resource currently have create and issues within the corporations, also as for the activating the service sector, in which the quality of interaction between costumers and service providers is very important for the success in the business ac tivity. Airline companies have increase on the human resource strategies and policies to make use of them in the company values (Heracleous Wirtz, 2009). This essay presents the most relevant human resource management practices to be adopted by JAL to cope up with the various problems. According to Kearns (2010), For most of the 20th century, the number of tasks and levels in large organizations grew incrementally, with new job and career opportunities to full-time employees. Opening the phase of 21st century have been about fundamental changes as because of many factors include global developments on technological and economical, also in labor market trends as well as the need of flexibility (Holbeche, 2009). As such, organizations have to temporary cancel some of their operations or closing the facilities. Need for cost reduction, plus speed and flexibility have made an organization to decrease a full-time employees result in temporary employment. Global labor market trend is constantly facing an extensive transformation in which cause difficulty in recruiting an employee and to maintain quality workers (Hunter, 2006). Hence, private and public organizations are becoming reliant on alternative employee work patterns. The first step to be taken at JAL is to realis tically analyze the current state of all HR-related matters and to develop a concept for its future development. This will revolve around the issues of market changes in coming years and the companys skills and core competences. The management of people in the airline company is complicated by the pro-cyclical nature of the industry and the proportion and malleability of labor costs (Boswell, Bingham Colvin, 2006). These factors have combined to necessitate cost cutting and to insure that those cuts are often focused on the labor. Competent management of people in airline is extremely important. Pilots occupy a position of considerable bargaining power and have not been averse to exercising that power. Flight crew is also an extremely valuable commodity for airlines due to their extensive training and their scarcity (Harvey Turnbull, 2006). It is imperative, then, management generates a committed and satisfied flight crew community. As per Kearns (2010), The business plan should include a description of organizational structure, including management and human resources capabilities, philosophy and needs, the number of employees intended to hire, how to manage them and the estimated personnel costs. The objective of the HR action plan at JAL should be to build JALs institutional capacity, productivity, and efficiency by effectively managing its most important asset, its staff. At the core of the HR action plan are measures to enhance and update HR management to attract, motivate and retain high-quality staff with the technical skills, behaviors and values needed to implement Strategy. This can be achieved by recruiting and developing staff with full commitment to JALs mission and the proactive attitudes essential for adapting to a changing environment; providing stable and clear mid- and long-term employment with more clearly defined career expectations; and offering an enabling environment in which staff can ful ly realize their potential to produce high-quality products and services (Ruefli, 2007). Given this relatively long-term employment model and the dynamic region in which JAL operates, the knowledge and skills sets of JAL staff need to be relevant and up to date. Recognizing the importance of keeping staffs technical skills sets current, JAL must in turn provide more learning opportunities. This will also support one of the thrusts of Strategy; enhancing JALs knowledge products and services. A key element in providing such an enabling environment will be for JAL to adopt best HR management practices so its staff and stakeholders recognize that HR is being managed properly and in full support of Strategy. These will include offering attractive and competitive conditions that are in line with those at comparator organizations; implementing HR actions based on performance and merit that are fair, reasonable, transparent and consistently practiced; and providing career development and learning opportunities to enable staff to develop and continually upgrade their skills in an evolving environment (Miles Mangold, 2005). Collectively, these measures are expected to address most of the issues highlighted by staff. These included career development and progression, performance management, staff development, salary and benefits, work-life balance. More effective communication with staff to manage the change is essential for JAL to achieve the intended impact for all actions. In order to define a framework for development, SWOT (strengths, weaknesses, opportunities, threats) and PESTLIED (political, economic, social, technological, legal, international, environmental and demographic changes) analyses are helpful for JAL (Hamill, 2006). Customer and employee surveys can provide important information about the various stakeholders interests. Analyses of competitors indicate current market position. But how does the company want to position itself on the market in the future? A vision helps the company define its aims and objectives (Doherty, 2005). This way, JAL can decide whether it wants to focus on price, innovation or customer relations. When the company has developed visions and aims based on upcoming challenges, they can check what skills already exist. They can then compare the current situation with future requirements using such tools as a qualifications matrix or a dynamic training requirement analysis (Holbeche, 2009). FAQs at such a time for JAL are: What should our employees do differently in the future, and Why are not they doing this already? But one also asks, what distinguishes a good employee from a bad one? At JAL, the human resource functions need to be called as the People Department. Recognizing that the people are the competitive advantage, there is a need to deliver the resources and services to prepare the people to be winners, to support the growth and profitability of the company, while preserving the values and special culture of JAL. The importance of HR should be reflected in every human resource function. Recruitment, selection, training, performance management, compensation, benefits and labor relations all should be supportive to JALs business strategy (Heracleous Wirtz, 2009). As a manager of a human resources department, diversity initiatives, team building, and leadership development would be very important parts of the strategy (Pate Beaumont, 2006). There are several reasons for this. The goal is to keep the best and most energetic people with the company. Develop leadership can work along with personal goals with corporate goal and improve the trust to the organization. It also shows a sincere effort to improve the individual. Team building helps improve a sense of belonging and loyalty to the company. Many people who are known to each other and have common interest tend to work better together (Miles Mangold, 2005). This will make an environment in JAL where it is pleasant to work and where employees are more inclined to help each other, especially during a crisis. Safe and happy workplace make employees feel good to be there. Each individual is given importance and provide security that give them motivation to stay on. This usually can be achieved by surveys to be able to find out the satisfied level of the employees (Hamill, 2006). Open Management Employees dislike the feeling of not knowing the state of what happening in the company. They would feel more motivated when they have part in discussion of company policies, sales, clients, contracts, and objectives (Ruefli, 2007). This encourages participative management. Ask the employees for ideas on how to improve would make them think more creative. Being open about everything related to company, will help building trust and motivated the employees in JAL. Open management policy and be use and practice using several tools. Good performance should be reward, such as bonuses or giving other compensation for well done job. With this reward system organization would not be struggle to keep up with attrition rate (Ruefli, 2007). Even if it is employees job, completion in an appropriate and acceptable manner would create a more profitable profit, and this also can boost up the staff morality (Hunter, 2006). These incentive can be use at JAL, individual or at team level, this have been observe that this works, getting the best out of employees. Still the reward should not be given without reason unless it is for annual bonuses. Doing so would reduce the perceived value of bonuses (Kearns, 2010). It is a well known for HR managers that hiring managers would try to begin the hiring process for a candidate that only have little idea of what exactly they are looking for (Boswell, Bingham Colvin, 2006). Even when job description is available for them to refer to, they must be kept on reminded to use it as a reference tool or else they are wasting everybodys time. Hiring managers must review what it is that they are looking for. Each year, requirement and criteria change. It is necessary to post all jobs that is vacant on company website so that everyone knows about it can apply for that some might be qualified (Harvey Turnbull, 2006). Candidate must need to conduct on behavior and technical test first, and then telephone screening, next as for face-to-face interview. The first advantage of testing is that there are no surprises later about their abilities. It make recruiting process tighter and more quality quantified and having constant process make recruiting consistent acros s all departments (Doherty, 2005). JAL should publicly explain almost every detail of the practices to be used to select employees. In theory, any company could attempt to copy the process and claim it as their own, but it would probably fall for a number of reasons. At JAL, much more energy and time should be expanded on the process. To find the right people, they should spend the money up front on the selection process, in the belief that it will become worthwhile over time (Ruefli, 2007). What should managers at JAL look for in the selection process? The approach should place great emphasis on hiring based on attitude. The search should be for something that considers to be elusive and important: a blend of energy, humor, team spirit, and self-confidence. These key predictors should be used at JAL to indicate how well applicants will perform. There should be centralized process that will help the organization as the applicants will have to go to one place and specialists trained in selection techniques can assist in the process of deciding which candidates should be hired and where they ought to be placed. JAL should keep the line managers and other employees involved in the process, and doing so will benefit the company for a number of reasons. Employees who will get the opportunity to contribute in the selection of their team members will become more committed to helping them succeed, and the process will also give them a sense of urgency (Pate Beaumont, 2006). The involvement of all levels of management and employees along with the HR department in the selection and placement process will help in building a strong network of employees. Thus, it will help JAL in providing the right attitude and service to its customers. There should be sound procedures in place for any level of selection, be it in the form of personality tests, interviews, or other assessments (Ruefli, 2007). The selection and placement decisions, however, should be ultimately made by a combined panel of line managers and specialized representatives from the People Department. These decisions will seem to be made with the full participation of present employees in the spirit of true partnership. There should be great emphasis on specialization and training. The training of new hires should be focused on building relational competence as well as functional expertise. Each new hire should receive classroom training and on-the-job training (Boswell, Bingham Colvin, 2006). Orientation should include ample exposure to JALs culture. Training should be broadly focused so that the new employees understand the jobs of other JAL staffers they may have to interact with. This will help employees to understand how their job fits and they can support others, consistent with the team aspect of the culture. At JAL, sharing of information such as contact and financial information with employees is a must so that they would understand the decision that has been made (Doherty, 2005). Passing this process, employees learn about the business, which is more than just a creative subject. This involves making a strategic decision to allow on contracts that are along with business and strategic business models (Hamill, 2006). People have knowledgeable and understand where money comes from and go to. They know what happen at bonus time and why it does or doesnt get paid out. People become more knowledgeable about business and feel more importance about their contribution and impact (Ruefli, 2007). Employees have changed their focus on just their job to the whole company. The importance of labor relation cannot be underestimated in any company (Harvey Turnbull, 2006). As the JAL employees union members and IASCO employees were not have the union less bargaining power. Pay and benefits of all empl oyees should be specified through the collective bargaining. JAL began to hire non-Japanese employees and pay labor wages. All employees should be paid equally at or above-market pay. It should introduce the profit sharing plan. Stock purchase plan should be introduced which will allow employees to purchase stock shares from payroll deductions at a discount (Miles Mangold, 2005). JAL should provide attractive benefits packages. Employees should receive medical insurance, dental insurance, vision coverage, life insurance, long-term disability insurance, dependent care, adoption assistance and mental health assistance (Doherty, 2005). This will let employees to know how much they are valued by helping them in times of need, be it with financial assistance or something else. Moreover, there should be job security. JAL should not have a layoff and it will help the employees to realize that job security is an important benefit provided by JAL. Paying bonuses or having any kind of variable compensation plan can be either an incentive or a distraction, depending on how it is administered and communicated (Pate Beaumont, 2006). Bonuses should be giving out in a way that the employees understand that this payment is due to the company hits a certain level of profitability. Then the criteria of giving out can be base on team success and individual success. It is based on performance, criteria is consistent for everyone, it is related for the employees to the success of the company, brings the necessity profit into reality, creating people to focus more on team (Harvey Turnbull, 2006). JAL should incorporate profit sharing, stock options, other non financial-based incentives, and a great communication plan for when a bonus plan is there. JALs employees evaluations should be based on demonstrating the spirit of outrageous customer service. Managers who will give an employee superior performance ratings must include documentation of actual examples of exemplary customer service that warranty the rating. Performance measures to be used should be cross functional (Kearns, 2010). This will motivate cooperation rather than competition. At most of the airlines, delays are attributed to specific units such as fueling, cleaning or baggage handling. At JAL, delays should be tied to the entire team or process, reducing blame shifting, and encouraging employees to assist other functions when needed (Miles Mangold, 2005). Performance measurement should be used as a performance management tool to foster cooperation, learning, and improvement. This essay is attempting to solve the problems faced by JAL. Eventually, employees form the greatest asset and must be continuously nurtured and developed as company strives to maintain reputation for excellence in the highly competitive global air travel industry. JAL should adopt a multi-faceted approach which incorporates all aspects of HR, which serves its employees from Recruitment to Retirement. There is a need to continuously improve processes and strategies. The people factor should be given top priority across the whole organization. Feedback and inputs from management, other divisions and diverse employee groups should be welcomed, and this will immensely contribute towards improving the standards and quality of output. JAL should have such an environment in which people can work well to the best, including the enjoyment of working that employees can develop, and be able to perform the most out of their ability and talents.