Ap European History Renaissance Education Dbq Exercise Essay

During the Renaissance, scholars became more interested in the humanistic features of society, and humanistic educators based their teaching models on Greek and Latin classics. Renaissance education was One apparent purpose of a Renaissance education was to praise the value of useful education, through the teaching of the classics, mainly Greek literature that was written by Greek philosophers, mathematicians and other important figures. Some criticised the Renaissance education, however, because they felt as if it was absurd, as it didn’t teach true values of learning, and didn’t teach one how to behave, but rather how to dictate Latin. Despite these criticisms, other humanists believed Renaissance learning brought great profits, higher positions, and more honors later in life, and was successful in the task of teaching young people to fear god, have good virtue, and to be disciplined. One apparent purpose of a Renaissance education was to praise the value of useful education, through the teaching of the classics, mainly Greek literature that was written by Greek philosophers, mathematicians and other important figures. Aeneas Sylvius Piccolomini, stated on his book, On the Education of Free Men, 1450, that the study of the Philosophy and of Letters was the guide to the meaning of the past, present, and even future. There may be some bias to this statement, for Piccolomini was an Italian humanist who later became pope, and may have been using his knowledge of the classics, being a humanist, to justify his religious and political power. Battista Guarino, an Italian humanist educator, also supports the classics, by simply explaining that mankind must learn and train in Virtue, or as the ancients called the â€Å"Humanities. † There is also a bit of point of view, however, because being an Italian humanist educator, Guarino would value the teaching of the classics to his students and would want to influence his opinion on others. Baldassare Castiglione, Italian diplomat and author, said that a courtier, or a king’s assistant or servant, should be educated in the humanities, and the Latin poets, orators, and historians, because women value that knowledge in a man, and he will be able to judge the writing of others. Erasmus also stated that the student must delve into the literatures of ancient Greece and Rome, to gain the knowledge in the classics. Erasmus has a particular point of view, because he practiced a humble religion, and tried to live the way Jesus lived, which would make him value things the ancients valued. Some criticised the Renaissance education, however, because they felt as if it was absurd, as it didn’t teach true values of learning, and didn’t teach one how to behave, but rather how to dictate Latin. Juan Luis Vives, a Spanish humanist, supported the idea that women should not learn much, but rather just enough to teach her good manners and literature from biblical scholars. There is a great deal of bias in this idea, because being Spanish, Christian, and male, Vives would not agree with women being educated, due to the fact that Spain was very conservative, especially after the Reconquista. Michel de Montaigne argued that the â€Å"absurd† educational system taught students the wrong values, by teaching them that writing the best Greek and Latin was more important the which books contain the best opinions. Montaigne’s point of view comes from the fact that he is a skeptic and criticizes numerous things, so it is likely that he would criticize the educational system. John Brinsley, an English schoolmaster objected that scholars at fifteen or sixteen years of age due not understand true knowledge, but instead the can only wrote Latin that means little. Brinsley had an interesting perspective, because he was a schoolmaster himself and saw these actions firsthand, from his young scholars. Another criticism of the school system was that such study weakens the body, and prevents people from obtaining jobs necessary to society, such as farming jobs, soldiers, and merchants. John Amos Comenius, and educational reformer, also said supported the idea that learning did not assist people enough in life, because students learned much grammar, rhetoric, and logic, instead of things that would prepare them for action later in life. Despite these criticisms, other humanists believed Renaissance learning brought great profits, higher positions, and more honors later in life, and was successful in the task of teaching young people to fear god, have good virtue, and to be disciplined. Francesco Guicciardini stated that things that seem more decorative than substantial to man, such as skills like the arts, led to a good reputation of men and open the way to favor a princess. These skills also led to great profits and honors. The perspective in this statement comes from the fact that he was a politician, and witnessed how his education in these arts helped him to improve his rank in society, gain a larger profit, and other benefits. Some also supported the Renaissance education from a religious side by explaining that children who go to school learned virtue, discipline, and to fear God, which were important Christian values. In an analysis of the percentage of justices of the Peace who attended university, around 1562, in Kent, only two percent of justices had attended university. This number increased dramatically in 1636, when an astonishing sixty eight percent of justices had attended university. This clearly demonstrated the value of a Renaissance education, and how it led to higher ranks, for instance, justices.

Health Care: History, Developments, and Problems Essay

Health care is necessary in every individual’s well-being. A lot of individuals require health care in one way or another, for, unfortunately, illness—not to mention old age and the disadvantages that come along with it—are inevitable. While it may seem rather frivolous to many, it is necessary to understand the various aspects of health care, as well as the related issues to it, for this will help pinpoint necessary information in the advent one needs to undergo hospitalization and long-term care. Understanding Nonprofit and For-profit Hospitals The difference between nonprofit and for-profit hospitals is actually historical. Nonprofit hospitals are were originally found by religious organizations. In a sense, these hospitals are those which aim to help people out of kindness. It is stated that nonprofit hospitals tend to be more dedicated in caring for their patients because their motivation is to help people without expecting anything in return. However, one important issue regarding nonprofit hospitals is that their facilities and equipment may not be updated, for they are getting no returns for their service (Cutler, 2000). On the other hand, for-profit hospitals are those hospitals which eventually emerged from nonprofit hospitals due to one important factor: profit. for-profit hospitals earn money and can afford to develop their health care programs, as well as provide better equipment and facilities in order to provide better service. Apart from this, for-profit hospitals can fund health education for its employees as well as fund medical research. However, it is stated that for-profit hospitals might skimp on health care. Since for-profit hospitals have â€Å"shareholders who demand the highest possible returns† (Cutler, 2000, p. ), there is a tendency for the hospital to be stingy with its services in order to provide the business demands of its shareholders (Cutler, 2000). Trends in the Hospital Sector As the service of health care improved over time, a various amount of changes occurred. Currently, there are several trends in the hospital sector which are said to aim for organization improvement and better service. One of the most prominent trends in the hospital sectors is the consolidation of hospitals. This merging is done in order to ensure that some of the small hospitals are able to survive. Apart from this, merging is a way to improve health care quality, as well as strengthen their financial and organizational capacity. This will also end the competition between hospitals whenever there are scarcities in resources (Laschober, Wiley & Gelband, 1995). Another trend in the hospital sector is the increasing number of doctors who specialize in various fields of practice. This only means that hospitals have decided to focus on creating a more efficient means of treatment for patients through hiring a wide range of specialists who can provide the appropriate health care needed by a patient. Laschober, Wiley & Gelband, 1995). And lastly, the hospital sector has largely improved in its patient care through removing the hotel function of hospitals. Gone are the days that patients need to spend days lying on a hospital bed; there is now a significant increase in the volume of outpatient care and the trend is that patients who undergo same-day surgeries and are allowed to go home on the same day (Laschober, Wiley & Gelband, 1995). Long-Term Care in Hospitals and Nursing Homes Nursing homes are residential settings for individuals who need assistance; commonly, individuals who are admitted into nursing homes are there due to poverty, advanced age, living alone, impaired mental status, loss of ability to take care of oneself, heart disease, and dementia. Primarily, the criterion is that the individual must be sick enough to need nursing care, but not sick enough that he or she requires hospitalization. Read more: Problems of Old Age Essay The long-term care plan in nursing home involves assisted-living facilities (focuses on providing all of the basic needs), special care units (different units created to address different needs of specific residents in the nursing home) and resident-centered care (addresses the need of patients for increased quality of life) (Miller, 2009). On the other hand, long-term care in hospitals is very different; usually, patients require an array of services which are dependent on the their changing condition. This is referred to as integrated care, wherein every single condition is addressed differently. Also, unlike a nursing home, patients are not required to stay in for a long time in hospitals; they may eventually go to their homes under the care and supervision of home health agencies (Singh, 2010), whereas those who are admitted in nursing homes are predetermined to stay there. Also, the patient can move into different types of long-term care, depending on his or her condition—this can also mean that the services provided may either be long-term or non-long term (Singh, 2010). Long-term Care in the United States As seen in the aforementioned discussion, long-term health care is undoubtedly important in ensuring that patients are well-cared for during times of illnesses and weakness. However, currently, the state of the long-term care policy in the United States is rather problematic. For example, long-term care benefits cannot be collected for the Community Living Assistance Services and Supports (CLASS) program is still not running. The earliest predicted date when individuals can claim their benefits will be in 2017, which is a problem especially if some individuals need benefits to support their hospitalization and so on. Apart from this, this health care policy concerning CLASS does not cover individuals who are not working, such as those who cannot work or retired (Andrews, 2010). Summary As seen in the aforementioned discussion, health care has come a long way from being provided by religious institutions. It has developed systems for the benefit of its patients, as well as new policies. However, it could be seen in the current situation of long-term care in the United States, there needs to be more improvement in order to attain the appropriate policies to serve the people. In a nutshell, although long-term care has been developed appropriately, whether it is on a hospital or in a nursing home, long-term care policies which have been currently implemented, such as CLASS, will prohibit people from receiving the appropriate health care. Even if such program will provide more benefits for individuals compared to the private long-term care insurances, it, nevertheless, excludes other individuals from being properly cared for because it is not encompassing.

Latin America’s Access to International Capital Markets: Good Behavior or Global Liquidity?

Latin America gained independence in early 19th century. From that time on, it showed active participation in international business endeavors through borrowings. The active participation of Latin America in international capital markets started when independence wars emerge in the history of the region. The series of borrowings by Latin America to international capital markets was stopped when several Latin American countries defaulted in its payments. Hence, international markets disappeared before the Latin American countries as a source financial aid. In the year 1970, Latin America participated again in having access to international capital markets. But, that participation became short-lived due to the fact that Mexico defaulted in its financial obligations with international capital markets. As a result, all Latin American countries lost access to international borrowings. There are three main questions that trigger the people’s minds in relation to the research study. The first question is anchored on whether or not the erratic international capital markets affect the boom-bust pattern in Latin America’s participation in international borrowings. The second question is posed on whether or not the volatile nature of Latin America’s economies caused the boom-bust pattern in Latin America’s participation in international borrowings. And the third question pertains to whether or not international primary gross issuance is vital to Latin America’s economic condition. In line with that, a collection of issuance data for twenty Latin American countries was completed which resulted to the discovery of three groups of typical economies. The first group of typical economies pertains to those Latin American countries with active participation in international capital markets which include Argentina, Brazil, Chile, Columbia, Mexico, and Venezuela (Fostel & Kaminsky, 2007, p. ). The second group of typical economies is one with more limited access to intentional borrowings which is composed of Bolivia, Costa Rica, Dominican Republic, El Salvador, Guatemala, Honduras, Jamaica, Panama, Peru, and Uruguay (Fostel & Kaminsky, 2007, p. 1). The third group of typical economies is one without participation in international markets and with no international issuance bond and equity which is composed of Haiti, Nicaragua, and Paraguay (Fostel & Kaminsky, 2007, p. 1). The first group is the focus of the research study for the purpose of examining whether or not good behavior or global liquidity is the cause of the boom-bust pattern of Latin America’s participation in international capital markets business activities. Basically, the research paper revolves around the explanation on Latin America’s access to international markets. The performance of the trade account and the development of financing in soaring, average, and stumpy income countries are discussed with clarity. Besides, the skillful presentation about the evolution of transfers involving official and private capital flows is apparent. The in-depth discussion about the three international capital markets like bonds, equity and syndicated loans of which some Latin American countries gained access provides readers the necessary knowledge about the topic. The data presented by the researchers with respect to international gross issuance among the countries that belongs to the first typical economies is useful in understanding the development of the participation of Latin America in international capital markets. Hence, the research paper is successful in giving complete and reliable information regarding Latin America’s access to international borrowings. Finally, global liquidation may be considered vital to access in international capital markets for Latin American countries, but still good behaviors matters most. This fact was exemplified by the positive performance of Argentina, Brazil, and Chile in terms of financial obligation payments during the 1990s (Fostel & Kaminsky, 2007, p. 1). The result of such superior performance is eventual macroeconomic stabilization.

Outliers Assignment Example | Topics and Well Written Essays - 1250 words

Outliers - Assignment Example He is a sports lover and has an attitude inclined towards psychology and research. In his literature psychological and sociological issues are delved deeper by the use of sports at all levels. Gladwell said; "Im not sure that the boundaries that used to exist among different recreational activities will matter as much in the future." Gladwell is the writer of four books, all successful. He described his brainwave of writing as; "I have two parallel things Im interested in. One is, Im interested in collecting interesting stories, and the other is Im interested in collecting interesting research. What Im looking for is cases where they overlap." The Tipping Point gives a new way to understand world, Blink changed the view of thinking and Outliers transformed the understanding of success. He really is a gifted man with the ability to see beyond those simplicities which others ignore. Outlier is a statistical term which is used to define points which do not follow the trend. Literally an outlier is the odd one out, the different, the status quo breaker, the one who brazen out the routine and the one who has the ability to challenge the norms. The book â€Å"Outliers† is itself an out of the box idea of Gladwell. Like his previous books, Gladwell, in Outliers has followed his tradition of challenging the status quo. The name itself has embark an extremely different and entirely new definition of the term; â€Å"Outliers†. After reading â€Å"Blink† the initial two seconds spent on looking the book comprised of the name; â€Å"Outliers†. My very first opinion influence through the name of the book was that it will be a powerful piece of literature. To me the hypothesis is successful, decisions made in mere two seconds are as good as the decisions made cautiously and deliberately. The book; â€Å"Outliers† is as powerful as the name itself suggests. Gladwell has used the term â€Å"Outlier† to represent the successful people of the world. He talks of those

Left Bank Group Analysis Research Paper Example | Topics and Well Written Essays - 1250 words

Left Bank Group Analysis - Research Paper Example Likewise, as with many movements, the New Wave movement was something of a conscious rejection with regards to the subject matter, stylistics, self-actualization, and experimentation that seemed to be so devoid in the periods prior to the development and nominal success that the New Wave movement was ultimately able to engender. Furthermore, like so many other artistic movements throughout history, the full scope of the importance contributions that the New Wave movement brought to cinematography filmmaking were of course not realized completely or appreciated accordingly during the time that they were being developed. Nevertheless, although many aspects of the New Wave movement were so experimental that they existed only within the confines of the current time in which they were developed, many of the experimental techniques and new ideas with which these filmmakers sought to integrate continue to have found measurable effect on some talk to the current Europe. Accordingly, this bri ef analysis will seek to understand, identify, and draw inference on the means by which one such group of influential French filmmakers from this New Wave movement contributed to a more complete and nuanced understanding of filmmaking is the hope of this author that such an analysis will engage the reader with the lasting importance that this group of film makers continues to exhibit. As such, the group to be analyzed will be that which was dubbed â€Å"Left Bank†. ... nown, were referred to as the Right Bank; likewise, the group of filmmakers which will be analyzed herein came to be known as the Left Bank (Reeder 63). This was not only a reference to the geographical meaning of where these individuals hailed from within Paris, but also a thinly veiled allusion to the political views espoused by the latter group. One of the greatest differentials came to be seen between the right bank as compared to the Left Bank directors was with regards to the level and approach that these Left Bank directors viewed the relationship between cinema and art. Whereas more traditional numbers of the New Wave movement saw literature and other art forms distinctly separate from cinematography, the Left Bank directors saw them as one and the same attempt to incorporate many of the avant garde and cutting edge techniques and ideas that were being pioneered within the art world within the cinematography that they created (Schwartz 147). However, as much as one might seek to distinguish the Left Bank New Wave filmmakers from their other counterparts within the New Wave movement, the reality of the situation was that they were oftentimes almost identical with regards to the approach to cinematography that they made. In reality, both schools of thought sought integrate a high level of modernism within current cinematography; the only means differential and/or to supreme that existed with regards to this modernism was where the inspiration for it could ultimately be drawn. To the Left Bank filmmakers, this inspiration was available from both existing and previous arts. Regardless of the level to which critics may seek to portray these groups as being in opposition to one another, the fact of the matter is that there was never any ill will between either the

Lasers Essay Example | Topics and Well Written Essays - 1500 words - 1

Lasers - Essay Example 13). â€Å"The invention of the laser was one of the groundbreaking scientific achievements of the twentieth century† (Lang and Barbero vii). This technology resulted in the development of new systems of communication, optical devices, space exploration, digital devices, and the mastery of nuclear energy. Lasers are oscillators functioning at optical frequencies producing monochromatic, coherent, and highly collimated intense beams of light. The frequencies of operation lie within a spectrum of far infrared to the vacuum ultraviolet or soft X-ray region (Lang and Barbero xii). This process occurs â€Å"when a beam of light passes through a specially prepared medium and intiates or stimulates the atoms within that medium to emit light† (Silfvast 1). Light is emitted from a source such as a flash lamp or diode, and the light is amplified in the lasing media which may be a gas, liquid, or solid. â€Å"The light travels between two mirrors; one of the mirrors is 100% reflective, while the other is partially translucent† (Dajnowski et al. 13). Light repeatedly passes through the lasing media until it gains the required energy level, at which point it exits through the partially reflective, translucent mirror, state Dajnowski et al. (13). The light is released in exactly the same direction and same wavelength as that of the original beam. Thus, lasers are devices that â€Å"amplify or increase the intensity of light to produce a highly directional, high-intensity beam that typically has a very pure frequency or wavelength† (Silfvast 1). The components of a typical laser device include an amplifying or gain medium, a pumping source to channel energy into the device, and an optical cavity or mirror arrangement for reflecting the beam of light back and forth through the amplifying medium for further increase and intensification. â€Å"A useful laser beam is obtained by allowing a small portion of the light to escape by passing through one of the mirrors that is

Answers for questions Assignment Example | Topics and Well Written Essays - 1000 words

Answers for questions - Assignment Example b) The miotic phase whereby the cell divides; this stage of the "cell cycle" comprises of two stages. First is mitosis, which is the division of the cell nucleus; this gets followed by cytokinesis, which is the splitting up of the cell’s cytoplasm to two daughter cells. Question Two Atomic bonds are in two types - ionic and covalent bonds; they vary in their structure, as well as their features. Covalent bonds comprise of pairs of electrons that two atoms share, and join the atoms in a permanent orientation; therefore, relatively high energies is essential  for breaking break them. The determining factor as to whether two atoms are capable of forming a covalent bond is dependent on their electronegativity that is the influence of an atom within a molecule of attracting electrons to itself. However, if two atoms vary considerably within their electronegativity, the result is one of the atoms loosing its electron to the other atom. In this case, the outcome happens to be a pos itively charged ion i.e. cation, together with a negatively charged ion i.e. ... The somewhat small size of water molecules paves way for many water molecules to bound one molecule of solute. As a result, the water’s partly negative dipoles get attracted to the positively charged constituents of the solute; this is the same with the positive dipoles. Question Four Osmosis is capable of producing disastrous impacts in living things; this is worse when a person drinks salt water like the ocean water. The body has the capability if handling a little bit of salty water, but if a person consumes salt water only for several days, the osmotic pressure starts drawing water from other sections of the body. Considering that a human body varies from 60% water i.e. in an adult male up to 85% in a baby, the body contains a lot of water; nonetheless, water is the vital ingredient within the human body. Therefore, if a person continues ingesting salt water, he or she will eventually undergo dehydration and die. Question Five The primary distinction between DNA and RNA ha ppens to be the sugar present within the molecules. Whereas the sugar available in a RNA molecule turns out to be ribose, on the other hand, the sugar available in a molecule of DNA happens to be deoxyribose. Although Deoxyribose is almost similar to ribose, the difference is that former contains one more OH. It is impossible for DNA to survive as a single molecule; rather, it exists as a tightly-bonded pair of molecules. The two long components entangle like vines, taking the shape of a twofold helix. This array of DNA strands is antiparallel, with the asymmetric tops of DNA components getting known as the 5? and 3? ends. The main differences amid DNA and RNA happens to be the sugar, with 2-deoxyribose getting replaced by the

Romney will argue Obama has failed to meet promises Essay

Romney will argue Obama has failed to meet promises - Essay Example The use of ethos was also inappropriate especially when Romney cited his religion (Mormons) to be the source of his â€Å"disciplined character†. In effect, the use of ethos alienated the rest of American voters who are non-Mormons. Political speeches are not board meeting speeches, where informations are stated as a matter of fact. Political speeches are the candidate’s tool to connect to his or her audience, which in this case are the American voters, to move and inspire them to vote for him or her to office. Romney’s speech may be well intentioned to address the present economic woes of United States which could be the most important issue of the day, but it does not capture the voters imagination. It focused so much on logos such as â€Å"to confront the nation’s economic problems† (Shear 1) and little on the effective use of pathos emotional appeal. He may know the problem that is besetting America but his voters does not get it. There were att empt to connect with the audience particularly the women quoting ‘Why should women have any less say than men about the great decisions facing our nation? . . . and that I can still hear her (his mother) saying in her beautiful voice† (Shear 1) but it just sounded so insincere and patronizing. American voters are sophisticated enough to realize the intention of his statement. It sounded so contrived that it made him looked manipulative that removed the integrity or ethos of the speech. Romney knows the power of ethos in reaching to his audience evident with his attempt to use ethos but he is not as crafty as Obama who speaks in the language of â€Å"rising ocean and healing the planet† when he intend to address an issue such as climate change. The article also largely focused on Romney’s candidacy for the Presidency than Obama’s. It discussed at length Romney’s issue against Obama’s failure as a President citing for example â€Å"the d isappointment of the last four years† (Shear 1). But despite of the length of his attribution towards Obama’s leadership, he failed to convince voters as the poll would show that Romney remains â€Å"Less well liked among voters than  Mr. Obama† (Shear 1). The article only cited one instance of Obama’s political snipe at Romney’s character which â€Å"portrayed him as a wealthy, out-of-touch business executive who cares more for profit than people† (Shear 1) and it eroded all the character build up or ethos of Romney. The tirade was craftily composed, despite lacking in logos because it turned Romney’s asset of being a successful entrepreneur who could get things done into a liability. The statement packaged Romney as somebody who is spoiled and out of touch that Americans voters cannot relate. The statement was based more on pathos or an appeal to emotion by painting Romney as an elitist brat in the imagination of American voters. T his political branding of course is untrue and lacked basis or lacking in logos because Romney will not be successful as he is now if he is a spoiled brat who lacks a grasp on reality. But the tirade stuck in the voters’ consciousness and hurt Romney’s image as a leader and alienated him from the consciousness of many Americans. What is more brilliant with the political branding was that Romney does not seem to realize that every time he speaks or people around him speaks business like, the more the political tirade will hold

Gosling & Mintzberg's The Five Minds of a Manager Article

Gosling & Mintzberg's The Five Minds of a Manager - Article Example To succeed, therefore, as a manger, one must have different mindsets at different times. Jonathan Glossing and Henry Mintzberg analyses these as the five minds of a manger. In doing this, they discuss the five most important roles that mangers do and the challenges they face in doing so. Managing self is the first of these; before managing a group of grown adults, one must manage himself. In doing these, such aspects of personality as grooming and punctuality among others are considered. One cannot purport to manage others while they portray signs of negligence at the workplace. Managers must therefore be very organized and orderly people. These are prerequisite to the achievement of the organizational goals and objectives. A dedicated and effectively self managed individual motivates his workforces who thereafter emulate his progress. Self discipline and restrain elevates a manager from the rest of the pack at the organization. It makes the manager authoritative and develops an air of self worth around him. It is only after ensuring this that a manager begins the process of managing the individual personality at his disposal which he does in accordance to how he manages himself (Jonathan and Henry 3). Managing organizations is the second mindset. An organization refers to a group of people brought together to achieve a common objective. A manager must weigh the task and put it in comparison to the human resource and other resources at his disposal necessary for the completion of the task. The manager is in charge of the task and he is responsible for the outcome. He must therefore ensure that he employs the best minds and competencies for the task to guarantee a positive outcome. The process of determining the best mindset requires skills and experience which a manager is required to posses. The third mindset that managers must acquire is to manage context. Organizations exist in societies; it is therefore natural that more

Compare and contrast Stopping by woods on a snowny evening & The Road Essay

Compare and contrast Stopping by woods on a snowny evening & The Road Not Taken - Essay Example The woods, although beautiful and serene, represent a dark and lonely place away from society and responsibilities. This isolation is tempting and seems to offer peace and quiet but is something no one would want or advise. For example, even the owner of these woods is away in his village on this â€Å"darkest evening of the year† (8). The village symbolizes society and civilization and is separate from this lonely, isolated spot so that even the owner won’t know that this visitor was here. In â€Å"The Road Not Taken†, the narrator comes across a fork in the road and is presented with two choices. Both are seemingly the same and there is no sure way to choose the right one, â€Å"the passing there/ Had worn them really about the same† (9-10). What matters most is that a choice has to be made. The narrator does, however, spend a lot of time judging his decision (Fagan 295). For example, he looks down one path and analyzes it as best he can, â€Å"long I stood /And looked down one as far as I could/ To where it bent in the undergrowth† (3-5). Also, the narrator realizes that any choice he makes will lead him to other choices and he won’t be able to come back to the first one. In both poems, Frost uses nature imagery to symbolize the journey of life. For example, in â€Å"Stopping by Woods on a Snowy Evening†, the woods represent a place and choice away from society, free from any obligations. Similarly, in the â€Å"The Road Not Taken†, the two paths in the woods are symbolic of life’s critical choices and decisions that one has to make (Fagan 295). Also, the imagery of grass represents the people that have already traveled down that particular path. Both poems also allude to the fact that both narrators have a long way to go and that their journey does not stop at these woods or cross roads of life. For example, in â€Å"The Road

Reducing your carbon footprint Research Paper Example | Topics and Well Written Essays - 750 words

Reducing your carbon footprint - Research Paper Example The term itself, Carbon Footprint, has very little to do with drawings or the footsteps we make in the sand. In this case, the term is a metaphor for the way that our activities impact the resources of the planet. Carbon Footprints relate to the way we use the natural resources of the planet and how fast we use it. Therefore, a Carbon Footprint: â€Å"... is a shorthand to describe the best estimate that we can get of the full climate change impact of something. That something could be anything – an activity, an item, a lifestyle, a company, a country or even the whole world.† (Berners - Lee, Mike â€Å"What is a Carbon Footprint?†). Using this definition, it is easy to understand that we all participate in releasing carbon emissions and leaving our carbon footprints on the planet. Everything we do, from breathing to throwing away a piece of chewed up gum, has a direct effect on the health of the planet and our environment overall. That is why it is of the utmost importance that we learn to reduce our carbon footprints as we live our lifetime. Global warming is the method by which our planet is letting us know that it is ill. Since the signs of illness exist, it is up to us to cure it of the illness. Unlike human beings who can go to doctors for medication, our planet works differently. We are all its doctor. Our actions can either cure the illnes of make everything worse. According to Hayley Morris, founder and director of Impact Sustainability: Effective carbon management strategies along with corporate social responsibility provide us, as individuals and as businesses, with the foundation to ease that pressure and reduce the size of our carbon footprint that is stamping down on the tail of our beloved environment. Until recently as a society we have been coasting along the same old road, consuming every part of the environment we can possibly get our hands on without any regard for or awareness of the damage we may be doing to it (Morris , Hayley â€Å"reducing Carbon Footprint Benefits You and the Environment†). In other words, we are the cause of what is ailing the planet. By actively pursuing activities that increase carbon emissions into the air and decrease the planet's ability to reproduce our needed natural supplies such as food and chemicals for exygen creation, we are stifling the planet's ability to grow and nurture our existence on it. Climate change is a serious problem that is directly affected by the carbon footprint emissions that we make. In order to slow down or cure the problem, we must strive towards reducing these carbon footprint emissions as best as we can. For starters, we can do simple things such as unplugging appliances when not in use, using public transport or biking once or twice a week to reduce carbon monoxide in the air, buying energy efficient appliances, and properly insulating our homes for the cold months. By implementing these changes, we will find that reducing our carbon footprints also has positive outcomes for us as individuals. For example, opting to walk or take a bike ride rather than taking the car of public transport during short trips will increase our physical activity. This will lead to â€Å"reduced obesity and heart disease among the population while also providing our environment with reduced global CO2 emissions, small particle pollution, noise, and injuries. Another health related benefit of reduced carbon footprints is that by making better dietary choices, such as

Identity theft IQ test Essay Example for Free

Identity theft IQ test Essay The website, www. privacy. org, featured two tests namely â€Å"Identity Theft IQ Test† and â€Å"Workplace Identity Theft IQ Test,† wherein people can more or less determine whether or not that they are at risk of unknowingly divulging their identities through identification cards and allowing shady characters to use them. In â€Å"Identity Theft IQ Test,† I was asked to answer questions pertaining to how much and how often I revealed or brought out things that are prone to identity theft such as my Social Security number and insurance card among others. I was also asked if my identification numbers are the same in all my identification cards. I got a 50 on the test which means that I am moderately prone to identity theft. In the â€Å"Workplace Identity Theft IQ Test†the questions basically pertained to what businesses can do to protect the identity of its employees since almost all employers require several identification requirements before hiring prospective employees. I got 10 out of 20 which means I am again moderately at risk to identity theft. Basically, to protect myself and prevent criminals from using my identity to commit fraud, I have to avoid bringing with me identification cards, such as Social Security cards, that can give a lot of information about myself unless I really need them. Moreover, I can also protect myself from identity theft in the place where I am employed if I make sure that the company or corporation I am working can safely secure my personal records and files. If not, I should be the one to suggest measures that can prevent identity theft to my superiors. Finally, in third test, â€Å"MailFrontier’s Phishing IQ Test,† I was tasked to assess the legitimacy of 10 email samples commonly that people commonly receive from their subscriptions or banks, such as account verification and providing of identification, among others. I got a 10 out of 10 which basically means I do not easily believe emails that ask me to give information about myself.

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