Drugs and their uses

Disappear Disappear is commonly used to treat a wide range of conditions. These include anxiety, panic attacks, insomnia, seizures, muscle spasms, restless leg yeomen, alcohol withdrawal, Benedictine withdrawal, opiate withdrawal syndrome and miner's disease. Sanitation sanitation is a hypodermic drug used to control elevated cholesterol or hyperventilation's with exercise, diet, and weightless. Aspirin Aspirin is an antiparticle medicine. This means it reduces the risk of blood clots forming in your blood.Co-coda Co-coda is a compound analgesic which consists of a combination of codeine phosphate and perpetrator, used for relief for mild to moderate pain. Postman Postman is a phosphate drug used for several bone diseases including osteoporosis. Brushfire (Lasso) Brushfire (Lasso) is a loop diuretic used in the treatment of hypertension, congestive heart failure and edema. It's also used for hepatic cirrhosis, renal impairment, nephritic syndrome, and in the management of severe hype rglycemia in combination with adeptest reiteration.Do you know what these drugs are? Meteoroid (Cellophane, Reamer, Glummest, Forefeet ) Meteoroid is an oral antibiotic drug in the beguine class. This drug is for the treatment of type 2 diabetes, in overweight and obese individuals with normal kidney function. Warfare (Minerva) Warfare is an anticoagulant normally used in the prevention of thrombosis ND thrombosis's, the formation of blood clots in blood vessels and their migration elsewhere in the body.Responding (Airspeeds) Responding is an antispasmodic drug mainly used to treat schizophrenia, specification disorder, the mixed and manic states of bipolar disorder and irritability in caustic individuals. Citizens Citizens is a second generation antihistamine used in the treatment of hay fever, allergies, angiosperm and artistic. Together (carbonized) Together is an anticonvulsant and mood stabilizing drug used primarily to treat epilepsy and bipolar disorder as well as triggering neuralgia.

Management Function Essay

All organizations depend on group efforts. Teamwork and group action have become necessary in every day of life, and it will lead to the success in group efforts. The management will be very important to the groups because it can helps to achieve group goals, provides maximum resources to his or her team, minimizes the cost, establishes sound organization, and generates more welfare to his or her team. Management functions, manager’s skills, management control and strategic management process will be analyzed to define how an excellent manager should be. Four Management Functions The four management functions comprise the primary functions to the managers. These four functions which are planning, organizing, leading and controlling can be used in all fields of management, be it at a factory, a super market, a restaurant or even at home. Planning Managers need to perform the planning function to define goals, establish strategies to achieve these goals and develop sub plans to coordinate activities for his or her team members. For example, as a merchandising manager in the supermarket chain business, the manager needs to define what the target customers like Western people, South East Asia people or East Asians the supermarkets want to attract. After define the goals are attract more and more Asian-Canadian families, the manager need to establish strategies like bringing Asian-Canadian families fresh foods and introducing the diversity of Asian food culture at stores that offer exceptional convenience, service, and value to those Asian customers. Then, lots of sub plans like which kind of merchandises should be imported and the merchandises’ price setting strategies will be developed by the manager and pass to different buyers to follow up. Organizing Managers need to arrange job duties to his or her team members to achieve the organization’s goal. The managers will determine what tasks should be done, who will responsible for the task and how the tasks are to be grouped. For example, as the merchandising manager in the supermarket chain business, the manager needs to organize his or her team to different group and each group will in charge of different merchandises by categories like drink, snack, rice oil and noodles. After different teams have been organized, each team’s supervisor will be selected by the merchandising manager. The buyers will report to their supervisors and the supervisors will report to the merchandising manager. Leading Managers need to lead their team members to achieve the organizations’ goals. The leading function will require the managers to provide good communication skills and lead ship skills to resolve the behavior issues. As the merchandising manager in the supermarket chain business, some conflicts will be appeared with different buyers. Buyers will provide some products that buyers want to promote to be the promotion products in each week’s flyer, due to the limited space of the flyer, not all the products will be selected to be the promotion products by merchandising manager. The manager will use the communication skills and lead ship skills to let the buyers know why their products cannot be selected and what they should improve next time. Controlling The last management function is controlling. Managers need to evaluate and monitor employees’ performance and make sure every step is correct to achieve the goals. As the merchandising manager, the merchandises’ sales are the key performance index to evaluate buyers’ performance. Usually, merchandising manager will use category sales to evaluate each team’s performance and total stores sales’ growth percentage to evaluate the whole department’s performance. Skills Required by Managers Technical skills, human skills and conceptual skills are three most important skills required by managers. Though these three skills, managers can know more about the specified filed they are working, have better interpersonal relationship with people and have more ideas when facing the complex situations. Technical skills Managers need have strong technical skills in the specified filed because the managers need to deal with his or her employees when the employees face some difficulties during the working. The managers will give help and lead the employees to solve technical problems to achieve the organizations’ goals. For example, as a merchandising manager in the supermarket chain business, he or she must have strong purchasing skills, budgeting skills, know well with different merchandises that are sold in stores and inventory management skills. Human skills Managers must have ability to work well with different employees. Managers with perfect human skills, they can receive more and more trust from their employees and the employees can make full effort to achieve the organizations’ goals. As the supermarket chain’s merchandising manager, he or she should get well not only with different buyers, but also with store levels’ employees. If the manager can work well with store levels’ employees, the products that they imported can be displayed very well and follow merchandising department’s pricing strategies, as a result, the company’s goal can be achieved easily. Conceptual skills Managers must have ability to analyze and provide solutions when facing difficulties or complex situations. In the business world, top-level management positions usually required to have this skill. For example, as the merchandising manager in the supermarket chain business, when the new store will be opened, the manager will use conceptual skills to analyze what the best location is, what the best merchandises will be on shelf and what the target sales will be generated and so on. Also, if one of categories’ sales was continuing decreasing in the past several weeks, the manager need provide insight and solutions to the category team to help them overcome the difficulties. Two Views of Management Control Omnipotent view of management: The traditional view of managers is that they are directly responsible for organizations’ success and failures. When the organizations’ performance is poor, the managers should provide reasons and solutions; when the organizations’ performance is good, the managers should get the credit even if they only do little things to achieve the goals. Symbolic view of management Managers only have limited effects on organizational outcomes and performances because of the large number of factors like customers, competitors, government policies and economy outside the control of managers. Both omnipotent view of management and symbolic view of management purpose are to achieve organizations’ goals and provide the excellent performance to the organizations. As well, either omnipotent view of management or symbolic view of management, managers needs to make decisions within organizations when something happened. Like the merchandising manager in the supermarket chain business, if stores’ sales are continuing decreasing, whatever the reason is merchandises’ price are not attractive or the outside economy is in downtrend, the manager need provide insights and solutions to improve sales for the company. However, there are big differences between omnipotent view of management and symbolic view of management. The managers will in charge of everything for organizations’ success and failures under omnipotent view of management; but under the symbolic view of management, lots of external factors will affect organizations’ performance, so the managers do not have big effects on organizational outcomes and performances. As the merchandising manager in the supermarket chain business, when stores’ sales are continuing decreasing, the manager will think if customers do not like the merchandises that they imported or the merchandises’ price is too high for the customers under omnipotent view of management, then the manager will provide solutions to improve the sales; however, under the symbolic view of management, the manager will think about if stores’ sales were effected by strong competitions in the market or the downtrend of economy. Strategic Management Process Step1: identify the organization’s current mission, goals and strategies Explain: The mission, goals and strategies of an organization are very important to employees, especially for managers. Managers need to create scope work by step to achieve organizations’ goals, missions and strategies. Example: A supermarket Inc. mission is that attract more and more Asian-Canadian families, bringing Asian-Canadian families fresh foods and introducing the diversity of Asian food culture at stores that offer exceptional convenience, service, and value to those Asian customers. The merchandising manager need bring in more Asian products to the stores to attract customers. Step2: do an internal analysis Explain: An internal analysis about the organization’s resources and capabilities will be done to indentify the organization’s strength and weakness Example: The merchandising manager will do an internal analysis to indentify the company’s strength which is have different kinds of Asian foods cross grocery, produce, seafood and bakery and weakness which is lack of experience about what kind of western foods is suitable for Asian customers. Step3: do an external analysis Explain: An external analysis about the business environment, government policies, and competitions will be done to help managers know opportunities and threats for organizations. Example: The merchandising manager will do an external analysis to know the opportunities and threats for the company. Opportunities are more and more Asian families move to Toronto and lots of labor supply in the market. Threats are the strong competitions exist in Toronto’s Asian supermarkets field. Step4: formulate strategies Explain: After identify organizations’ missions and finished internal and external analysis, managers need formulate strategies to achieve organizations’ mission base on SWOT. Example: The merchandising manager formulates the strategy which is open more new stores to achieve the company’s mission. More and more Asian families move to Toronto and lots of labor supply in the market, new stores will be easy opened and can attract more Asian customers. Meanwhile, strong competitions exist in the market, the company need to increase the number of stores to low the products’ cost. Step5: implement strategies Explain: After managers formulate the strategies, lots of members will be involved to implement the strategies to achieve organizations’ goals. Example: The merchandising manager will request his or her buyers to import more Asian merchandises for new stores, work with the store operation department to decide the layout of stores and work with finance department about new stores’ budget. Step6: evaluate results Explain: After the strategies were implemented, managers need to evaluate the results to see if achieve the organizations’ goals and make any adjustments if necessary. Example: After new store was opened, the managers need to calculate if store’s sales had been achieved the target. If not, the manager will provide solutions to improve store sales immediately.

Organization Study at Sarathy Motors Kollam

AN ORGANIZATION STUDY AT SARATHY MOTORS, KOLLAM A report submitted in partial fulfillment of requirement for the award of degree of Master of Business Administration (CSS) of Kerala University Submitted by ASWIN M (Register No: 1105612) Under the guidance of Faculty guide Project guide Mrs. ANJU MURALEEDARAN Mrs. DEEPA M Institute of Management of Kerala University of Kerala Kundara September 2012 DECLARATION I, Aswin M, hereby declare that the project report titled â€Å"Organizational Study at Sarathy Motors in Kollam District has been done by me under the guidance of Mrs.Anju Muraleedaran , Faculty member of Institute Of Management, Kundara centre, University Of Kerala, I also declare that this project report had not been submitted by me, as fully or partially, for the award of any degree or diploma. Place: Kundara Aswin M Date ACKNOWLEDGEMENT First of all I thank Almighty God for all his blessing and for giving me strength, wisdom, and presence of mind in successfully completin g this project. I would also like to thank G.Rajesh, Coordinator IMK Kundara, for giving an opportunity to experience a working environment of Sarathy Motors. I am grateful to my faculty guide Anju Muraleedaran for his great support for doing my work. I would like to extend my heartfelt thanks to Mrs. Deepa M, HR Manager, Sarathy Motors for her helpful attitude to me. Finally I would like to thank all those who encouraged me in the completion of my project report. Aswin M LIST OF CONTENTS SL. NO| CHAPTER NAME| PAGE NO. | 1. | INTRODUCTION| 1-5| 2. | INDUSTRY PROFILE| 7-24| 3. COMPANY PROFILE| 25-33| 4. | ORGANISATION STRUCTURE| 35| 5. | ANALYSIS – OBJECT WISE| 36-62| 6. | SWOT ANALYSIS, PEST & PORTER’S FIVE FORCE MODEL ANALYSIS| 63-72| 7. | FINDINGS, SUGGESTIONS ANDCONCLUSION| 73-76| 8| BIBLIOGRAPHYAPPENDIX| 77-80| LIST OF TABLES AND CHARTS SL NO| TABLE/CHART| PAGE NO| 1| ORGANIZATION STRUCTURE| 35| 2| STRUCTURE OF HR DEPARTMENTS| 38| 3| STRUCTURE OF FINANCE DEPARTMENT | 46| 4| STRUCTURE OF SPARE DEPARTMENT| 49| 5| STRUCTURE OF SALES AND MARKETING DEPARTMENT| 54| 6| STRUCTURE OF SERVICE DEPARTMENT| 58|

MGM630-0804B-04 Applied Managerial Marketing - Phase 2 Discussion Essay

MGM630-0804B-04 Applied Managerial Marketing - Phase 2 Discussion Board - Essay Example The company deals with a variety of items and is well spread across the three state region in around 1 ten stores. The company has been in this business from 1992 and has not been very inclined towards brand building. The company dealt mainly with only importing and selling of home dà ©cor and gift items and is now looking at moving into house ware items as well. Efforts are being made to improve the brand awareness and also the product portfolio of the company. There are a few issues that the company might face in the case of increasing the brand awareness. Since the company has been in the industry for such a long period and has always used brown bags to wrap their products, there has been very little or almost no attention that has been given to the GGI. It is not known if the company even has a reputation in the market at all. Also as the company is just starting to move into a new product line – House ware, it is obvious that the brand has no awareness for this portfolio of products. Also with the declining sales in the whole sale business and the store business remaining flat, it is obvious that the company is lacking a lot of marketing. To resolve these issues it is essential that steps are taken to correctly market the company and increase brand awareness. To do this it is firstly essential to understand the role of marketing in a society and how it affects a firm. The next section will deal with understanding this in brief. As already mentioned earlier, marketing plays a very important role for every business. It is a process of identifying, anticipating and satisfying the customer requirements. Marketing can be done using a number of different tools like advertising, branding, direct marketing, publicity etc. It is essential that all firms understand one simple concept, that societies do not require marketing and can exist

Ethics in Communication and Public Relations Research Paper

Ethics in Communication and Public Relations - Research Paper Example Public relations also involves the organizations or individuals gaining exposure to their audiences using different topics, debates which are of public interests and news articles mostly requiring no direct payment (Seitel, 2007). According to Messina (2007), the aim of public relations in the company is to persuade the members of the public, their investors, employees, partners and other different stakeholders associated with it. The company persuades all the stakeholders to maintain a certain point of view about their products and services, the leadership and other issues including the political decisions. Some common activities involved in communication to public include speaking at conferences, working with the press to deliver information, and the entire communication by employees to the general public (Rubel, 2007). In this aspect therefore, normative ethics is applied by the individuals or organizations to determine the information delivered to the public if they are true or f alse. The amount earned globally in the communication sector, specifically in advertisements have barely declined and most of the traditional media outlets have declined their circulations in favor of social media and online news sources. The death of newspapers as a means to pass information to the public was even tracked as explained by Paul (2008).

The Lovely Bone Essay Example | Topics and Well Written Essays - 500 words

The Lovely Bone - Essay Example The story is set in Pennsylvania where Susie is returning home through a shortcut. Near the cornfield she finds a shelter made by Mr. Harvey who rapes and kills her. Three days later her elbow bone is found by the detective, Len Fenerman who tells this to her parents. Other evidences are found as Susie continues to watch her murderer from the heaven. After Susie’s father meets Mr. Harvey few days after her death, he begins suspecting him and tells his detective. Susie watches everything from haven including her sister Lindsey who breaks into Mr. Harvey’s house for evidence. Mr. Harvey who now fears he will get caught escapes the town. The case comes to an end as the detective is unable to solve it. Mr. Harvey dies in the end by falling into a crevice. Major changes occur after Susie’s death as her family starts to accept her death. Her parents are extremely sad at their loss and Susie’s father is convinced that Mr. Harvey has killed his daughter. Meanwhile Susie is watching all of this from heaven. Jack Salmon, who wants to find solid evidence against Jack sends Susie’s sister Lindsey to Mr. Harvey’s house upon which she finds evidence. The family starts drifting apart as Susie’s mother, Abigail has an affair with the detective to her murder case. Abigail leaves her family and goes to live in California. Lindsey grows up and starts a relationship with Samuel. Susie’s grandmother also comes to live in with her father. Jack still does not overcome the anxiety caused by Susie’s loss at which Susie’s brother Buckley tells Jack to focus on him too. After Jack gets a heart attack where Abigail comes to meet him and falls in love with him again. Towards the end, the family is reuni ted. Even upon finding no solid evidence against Mr. Harvey initially, Jack is very confident that he is guilty. Jack seems to be too much focused on Susie’s death that it overtakes his life and he can only concentrate on Mr. Harvey which

A new technology that is revolutionizing the healthcare with examples Essay

A new technology that is revolutionizing the healthcare with examples from journals or magazines - Essay Example Recently, hospitals around the world have escalated the use of 3-D printer technology in medical activities ranging from 3-D printing of an entire skull to rehearsing extremely complex surgeries. With the aid of 3-D printing technology, a group of researchers in US and China has printed various models of tumors which are cancerous to assist in the discovery of anti-cancer drugs. 3-D printing technology has also helped doctors in the understanding of how tumors grow, spread and more importantly, what make the tumors to develop (Ventola, 2014). With 3-D printing, cell analysis is considerably easy. Cell analysis is done by fabricating cells. Cell fabrication involves protecting cells with hydrogel for analysis. Essentially, when cells are in the body, they are never two-dimensional. As a result, they lose a lot of functionalities when they are placed on a flat dish for analysis. To protect cells from losing their functionality, they are put in hydrogel and then the structures of the cell are printed using 3-D technology. With these structures, analysis of cells is considerable accessible which make it easy to diagnose complicated ailments (Ventola, 2014). In conclusion, with this technology, quality health care can be guaranteed. Many medical institutions and governmental agencies today have fully understood the benefits that are derived from the use of this technology. This paper has discussed 3-D printing as the new technology that is revolutionizing health

Drunk Drivers Should Be Imprisoned on the First Offense Essay

Drunk Drivers Should Be Imprisoned on the First Offense - Essay Example Drunk driving must be dealt with a stern approach and one of the reasons behind dealing with the same is through punishing the first time offenders. This leads to a chaotic situation where imprisonment seems to be the only way forward. Imprisonment is therefore a grave reality which shall open the eyes of the offenders once and for all and it ought to bring solace to the pedestrians and other drivers on the road that have made no mistake to be present there. Moving ahead, it has been seen that drunk driving leads to problems of magnanimous effects as this has been researched upon through studies and evidence that has been discerned to date. Hence imprisonment seems to be the only harsh reality that can dawn upon an individual when he is doing the undoable, i.e. driving whilst being drunk. If the offenders know beforehand that they would be imprisoned for a set duration of time, they would abstain from getting into such realms in the first place. Also it would mean that the people wou ld have little choice than to forego this habit of theirs forever. These offenders would know that if they commit something wrong in the future, they would not be spared and hence their driving license would also be canceled as a result of the same. (Lobmann, 2002) is of the view that they will not be allowed to drive a vehicle until their license gets active again and hence this would serve as a deterrent to curb the menace of drunk driving all over the world. It is understandable that the problems which this individual will face under such realms would be immense but then again these are needed to tackle this issue once and for all. The accidents have increased all over the world. This is because people are in a rush to make it to their desired destinations. Also the fact that drunk driving cases have increased drastically. People just do not care if they have to make it to their destinations while they are in a state of being drunk. What they forget is the fact that drunk driving makes them feel dizzy and drowsy which is indeed quite a problem for the other pedestrians and drivers on the road. The latter feel that they are at the direct mercy of these drunk drivers and that they would have to do it themselves in the case of safety on the road. Wagner (2011) asserts what is even more discouraging is the fact that some people believe in drinking whilst driving which is doubly dangerous for just about everyone. However precautions need to be taken by the authorities to make sure that drunken individuals do not hit the roads. No matter what happens, it would be a good starting point to put them behind bars for a certain amount of time and revoke their licenses to curb this problem once and for all. From a personal example, I have seen cases when drunken individuals have come on to the road and created absolute mayhem. This has meant that they have lost their control completely and hit different vehicles on the road and even the innocent pedestrians. I have seen accidents so severe that I have not been able to sleep properly after that. What is needed however is an understanding that drunk driving is one form of evil that must be avoided as much as possible because it creates trouble for the people on and off the road. The property that is destroyed under such domains is another aspect that needs to be given proper significance as well. In essence, the drunken drivers should be told to spend some time in

The Changing Role of National oil companies in the international Dissertation

The Changing Role of National oil companies in the international energy Market - Dissertation Example Oil prices increased in recent years from about $20 to about $100 per barrel, thereby expanding profits for many national and international oil companies. With decreasing supply and increasing demands for oil, oil companies have been competing with each other to seek more substantive oil sources. The fact that majority of oil reserved are under government control is giving a major advantage for national oil companies on access to oil sources. Having control over these oil reserves has also brought about greater pressure for oil companies, mostly pressure in relation to their national roles and responsibilities, especially those which relate to supply and demand, globalization challenges, physical security, and international oil competition. 1.2 Background of the problem National oil companies are oil companies which are partially or wholly owned by national governments. Recent surveys from the United States Energy Information Administration indicate that about 52% of oil companies ar e nationally owned; and about 88% of oil reserved is controlled by national oil companies (Energy Information Administration, 2009). National oil companies (NOCs) have become dominant in recent years and in relation to international oil corporations, including ExxonMobil, BP, and Royal Dutch Shell, their dominance has gained much momentum. These NOCs have also increased their investments outside their borders. Some corporations have even abandoned their investments in various countries, as was the case for ExxonMobil abandoning its million dollar investments in the Orinoco basin in Venezuela (Mommer, 2001). This decision was caused by the breakdown of negotiations between the international oil companies on one side and President Hugo Chavez and Petroleos de Venezula (PDV) on the other (Kalicki and Goldwyn, 2005). Other international oil companies, including Total SA of France, Statoil of Norway, BP from Britain, and Chevron from the US agreed to raise the PDV share in the Orinoco pr ojects from 40% to 78% (Oil Daily, 2007). Under these conditions, ConocoPhillips found this decision very much unfavourable to their interests. The company was able to detect about 1.1 billion barrels of reserves from their interests in Venezuela and this represented about 10% of their total reserve holdings, and their Venezuela interests was equivalent to 4% of their total crude oil reserves (Oil Daily, 2007). ConocoPhillips suffered $4.5 billion dollar write-off under these conditions and was unable to meet its targets; as a result, its shares suffered a beating in the stock market (Oil Daily, 2007). On the part of Venezuela, PDV was able to increase its reserves and its production activities; as a result, it gained more power in the international oil market (Pirog, 2007). Venezuela has a major share in the crude oil imports of the US and their oil flow is not directly controlled by their government (Pirog, 2007). These conditions however, may not allow the crude oil market to fol low and be influenced by economic market dictates. The ranking of oil companies can be determined through various considerations. Various standards have to be used in order to evaluate the changing qualities of oil companies. In addition, investments in explorations and development are major considerations linking the present to the future, ensuring significant expansions for the company and preventing the depletion of reserves

Development of Modern Middle East Essay Example for Free

Development of Modern Middle East Essay The purpose of this paper is to give a synopsis of the life history and work of Muhammad, son of Abdullah, the prophet of Islam. It will also seek to address the persecutions he underwent at the hands of his own clan. Muhammad was and remains one of the most influential people the world has ever seen. He was a mortal, illiterate man who has changed world history and left an indelible mark on the history books. He was the last of the prophets and one of the few with scriptures. The scripture (Qur’an) is one of the most read and revered books on the face of the earth. His work has over one billion followers worldwide comprising people from all races, social status, sex and age. He acknowledged every prophet before him and discriminated against none (Qur’an 2:285). He was a human rights champion. In this paper Quraysh and/or Mecca will mostly refer to unbelievers in Islamic monotheism at the time of Muhammad. MUHAMMAD: BIRTH and CHILDHOOD Muhammad the son of Abdullah and the grandson of Abdul Muttalib (leader of the Quraysh tribe and custodian of al-Ka’aba) is the prophet of the Islamic religion. Muhammad was born in Mecca in the year 570 c.e. which is also known as the Year of the Elephant. This is the year that Abrahah, the king of Abyssinia (modern day Ethiopia) sent a powerful force to destroy al-Ka’aba because he viewed al-Ka’aba as a rival since it was attracting more pilgrims than his newly constructed temple in Yemen. According to history, on approaching Mecca the lead elephant of Abrahah’s convoy refused to enter the city. Then birds filled the skies stoning the army with pebbles so much so that they had to retreat in defeat. Muhammad was a descendant of Abraham through his son Ishmael. His father Abdullah died few months before Muhammad’s birth. His mother Aminah sent him the countryside to be nursed and nurtured as was the custom in Arabia. It’s believed that the children learn the qualities of self-discipline, nobility, and freedom better in the countryside than in the urban areas. It also gave them the opportunities to be speakers of eloquent Arabic spoken by the Bedouin. Aminah did not have much money to pay for the care so most of the caregivers would not take Muhammad until she met Halimah a poor Bedouin woman who became Muhammad’s nurse. One day while playing with his child peers, two angels appeared to him in human form, laid him down, opened his chest and purified his heart. For fear of what might have happened next, Halimah and her husband Harith returned Muhammad to his mother. (Britannica) Aminah died when Muhammad was only six years old. His grandfather (Abdul Muttalib) took custody of him, then two years later Abdul Muttalib fell sick and suspected he may not survive the illness, so he asked his son Abu Talib to take charge of Muhammad. Abdul Muttalib had many sons some of whom were richer than Abu Talib but he was the kindest and most respectable among his brothers. Abu Talib treated him very well and respectfully. ADOLESCENT to MARRIAGE At a young age he joined Abu Talib’s caravan to Syria. On this Syrian trip a Christian monk (Bahira) saw the signs of prophethood on him, invited him and his uncle to dine with him. He saw the prophet seal on his back and told Abu Talib to protect him from the Jews and Christians because might kill him if they realize his was the foretold prophet to come after Jesus (Qur’an 61:6) And [mention] when Jesus, the son of Mary, said, O children of Israel, indeed I am the messenger of Allah to you confirming what came before me of the Torah and bringing good tidings of a messenger to come after me, whose name is Ahmad. But when he came to them with clear evidences, they said, This is obvious magic. Muhammad was said to be a young man of unusual physical beauty and generosity of character. He was revered in Mecca due to his sense of fairness and justice that people often went to him for arbitration, hence the title al-Amin (the Trusted One). His uncle Abu Talib recommended him to Khadija to work on her caravan. He did so well that Khadija retained his service and made him the head of her caravan and proposed marriage to him through her friend. They got married when Muhammad was twenty five years old and Khadija who was forty years old. During marriage they had two sons and four daughters. The two sons both died young and only Fatimah among the daughters grew up to have children of her own. At age thirty five, Muhammad took his cousin Ali who was five at the time into his household and raised him. He later gave his daughter Fatima to Ali in marriage and it was through this matrimony that his progeny came. (Britannica) All these time although an illiterate, he was not satisfied with the spiritual lives of the Meccans. He started retreating to the mountains for meditation. He has seen, heard, and dreamed of miraculous things and beings. He maintained in his mind that there must be a supernatural being somewhere who is responsible for all these creatures. (CARM) CALL to PROPHETHOOD Muhammad continued his daily retreat in the cave on the mountain. One day, generally believed to be the night of power (Laila tul Qadr) in Ramadan at age forty in the year 610 c.e. while in the cave on mount Hira, the archangel Gabriel appeared to him in human form and asked him to recite. Muhammad told the angel that he did not know how to read but Gabriel insisted he recite the name of thy Lord (Qur’an 96:1-5) â€Å"Read! In the name of your Lord (Cherisher and Sustainer), He who created — created man, out of a leech-like clot: Read! And your Lord is Most Bountiful. He who taught (the use of) the Pen, taught man that which he knew not.† The appearance of Gabriel to Muhammad confirmed his call to prophethood which also marked the beginning of Islam, and added another important chapter to Arab and world history. Among the first converts to Islam were his beloved wife Khadija, Ali his cousin and later son-in-law, and his friend Abu Bakr. The words that Gabriel taught him became the first verses (Ayat) of the scriptures (Koran) which later developed to one hundred and fourteen chapters arranged from the longest to the shortest except the opening chapter (al-Fatiha) which is short. The Qur’an was revealed in a period of twenty three years (610-632 c.e), the first thirteen years in Mecca and last ten in Medina. Although not arranged in chronological order, the shorter chapters are the early revelations. The Qur’an is one of the most revered and read books on earth today. It is the most sacred book for the Muslims; they believe it is God’s own words (the original copy in heaven) and that Muhammad is the last of the prophets hence the other title the â€Å"Seal.† In this case Muhammad and the Qur’an are both completely beyond criticism (reprimand) in the Islamic world. The Muslims will go any length to defend both regardless of the consequences. (Britannica) EARLY DAYS of ISLAM and PERSECUTIONS For the first three years Islam had about forty followers (Muslims). Muhammad and the Muslims faced a lot of persecutions at the hands of Mecca pagans, who viewed the new faith as a threat to their polytheistic lives, and the religions of their forefathers. He was still preaching in private even after three years. He preached a lot about kindness to the poor and the weak (women and children), equality of races, equality of men and women before God. Muslims started gaining ground slowly but surely. Since Mecca frequently had visitors, the elders feared that the new faith might quickly spread if strangers started accepting it, so they had to hatch a plan to stop the spread. They continue to defend their religion but offered little new to the challenge Islam brought to them. Abu Lahab (Muhammad’s uncle) and Abu Sufyan gathered eloquent poets from the tribes and started a propaganda war. The poets coined choice phrases and recited well-crafted verses to ridicule Muhammad and call into doubt the veracity of his beliefs. Muslim converts with poetic skill began to construct rebuttals and soon there were dueling poets all over the city. People began approaching the once highly respected Muhammad in the streets shoving and asking him to perform miracles (predict market prices, turn mountains into gold, make angels appear, and etc.) like the earlier prophets did. Many Qur’an verses came down to him to answer the many challenges he faced and those that question the authenticity of the Qur’an. Muhammad frequently reminded them that he was just a mortal man and the Qur’an was his miracle. Another thing that puzzled the opponents was that Muhammad was not a poet, and his sudden eloquence and verbosity was inexplicable. The Meccans admitted to the fact that Qur’anic verses were nice to listen to and its contents were impassioned and appealing. Some clan elders began sitting outside Muhammad’s window at night to hear him reciting his beautiful verses. They enjoyed the verses and knew that those verses could not have come from even the best poet let alone an illiterate man. This continued until they shamed each other into stopping because that will mean they are encouraging Muhammad and admitting that he was on the right path. (Emerick Yahiya) He continued (Qur’an 7:194-198) speaking against asking idols for help even though the idols could not see, hear, speak, or protect themselves. These Qur’anic verses made idol worship look foolish. These assertions did not settle well with the Quraysh, so they approached Abu Talib (head of the Banu Hasim) and asked him to stop Muhammad or relinquish his protection of him so they could take care of him because he attacks their religion which was Abu Talib’s too. Abu Talib knew that to take care of him meant they wanted kill Muhammad. Remembering the promise he made to his father to protect Muhammad he politely told the clan elders that he would continue to extend his clan’s protection to Muhammad. Muhammad was preaching that slaves were equal to their masters at a time when slavery was at its height in Arabia. This alarmed the Quraysh leaders which prompted them to reason with Abu Talib for the second time, they took along an able-bodied young man (Umarah) to be Abu Talib’s adopted son in exchange for Muhammad. Abu Talib strongly rejected the offer. Meanwhile Muhammad continued his preaching and people continue converting to Islam. (Emerick Yahiya) The Quraysh elders tried a third time to reason with Abu Talib only this with an ultimatum and that was â€Å"Stop Muhammad or we will fight him and you.† Abu Talib did not want to cause trouble for his clan, called Muhammad to a private meeting and said to him â€Å"Save me and save yourself.† Muhammad politely responded his uncle by saying â€Å"Uncle by Allah, if they put the sun in my right hand and the moon in my left and ordered me to give up this cause, I would never do it until either Allah has vindicated me or I perish in the attempt.† When the response was conveyed to the clan leaders, they ordered redoubling of efforts to persecute Muslims. Abu Talib assured him of his unflinching support no matter what he preached and called the Banu Hashim and Banu Abdul Muttalib clans to swear to an oath to protect Muhammad. The Quraysh then sent Utbah, a conciliatory Arab leader to Muhammad asking him to stop preaching his religion or at least make accommodation for idol worshipping, then the Meccans would compensate him whatever he wished. Muhammad recited Chapter 32 of the Qur’an, which outlines the truth of monotheism, Allah’s purpose for creation, and the way He chooses prophets to convey His message of salvation. Utbah was convinced that Muhammad was not crazy and that he should be left alone. Persecution of Muslims then increased to an alarming rate. Muslims were tortured, starved, left to die in hot desert sands, and even murdered. MIGRATION to MEDINA (HIJRA) Due to the persistent persecutions from the people of Mecca, Muhammad accepted the invitation from Yathrib (modern day Medina) to be the head of the city and arbitrator for the warring factions. He could also have freedom to practice and preach about his faith. He migrated to in the year 622 c.e. with his family and some followers. When he was leaving his house Muhammad recited (Qur’an 36:9) â€Å"We have covered them so they cannot see,† he slipped out passing unnoticed by the men assigned to kill him. He left his cousin Ali to sleep in his house. Upon arrival at Yathrib, he and his companions were welcomed with loud cry of delight; a chorus of girls sang a welcome song for them. From that day Yathrib was renamed Medina (city of the prophet). The migration is known as Hijra which also marked the beginning of the Islamic calendar. (CARM) Islam started growing rapidly as a dominant political force in Medina and Muhammad assumed the role of a de facto head of state. Both men and women (including but not limited to Safiya bint Abdul Muttalib, Asma bint Abu Bakr, and Fatima bint Muhammad) played important roles as activists and teachers to make a homeland for Islamic monotheism a reality. Many women began to vigorously support the new movement, for Islam presented a great leap forward in both women’s rights and status. Islam was now going through radical changes. The changes included opposition to idolatry, improving personal morality, establishing personal relationship with God, and regulations for public and social life. The Qur’an laid new rules for the conduct of business and commerce, the compulsory 2.5% welfare tax (Zakat) from annual savings to be given for the benefit of the poor and needy. Fasting (abstinence from worldly pleasure during daylight) in the month of Ramadan was established. The five daily prayers were now held in congregation in the mosque. (Mission Islam) With the arrival of Sawdah and marriage to Aisha, Muhammad started to establish a stable household in Medina. Sawdah was a widow of ********* and one of the early converts to Islam. She got married to Muhammad after the demise of Khadija. She was said to be a very kind and humorous woman. Aisha may have been twelve years or so at the time. She lived in her own apartment by the mosque and spent her leisure entertaining visitors and walking the streets of Medina. Aisha was a quick learner and soon became a sought-after teacher on Islamic issues as the years progressed. Sawdah also had her own apartment and did not encroach upon Aisha’s domain. She took the inexperienced Aisha under her wing and guided her in her role as a wife. (Inter-Islam) WARS against DISBELIEVERS Muhammad and his followers fought many wars against Islam’s foes from Mecca, Jews and the tribes. The first of the great wars was the â€Å"Battle of Badr.† The Muslims were outnumbered by Meccans almost three to one. The Meccan army was headed by Abu Jahl a staunch enemy of Islam and the person of Muhammad. The Meccans lost their camp and its wealth and supplies, and about fifty men including Abu Jahl and many other leaders who died in the war. The Muslims took about seventy Meccans prisoner. The Muslims had fourteen casualties. Muhammad announced that Allah’s help allowed them to win (Qur’an 8:9 and 8:17). While the Muslims continued to celebrate their win in Medina, the Meccans were humiliated by the Battle of Badr at home and wanted to revenge. This will mean a change of events for the Muslims (Qur’an 3:140) â€Å"If a wound hath touched you, be sure a similar wound hath touched the others. Such days (of varying fortunes) We give to men and men by turns: that Allah may know those that believe, and that He may take to Himself from your ranks Martyr-witnesses (to Truth). And Allah loveth not those that do wrong†. This leads to the Battle of Uhud. The Meccans used the proceeds from Abu Sufyan’s great caravan to procure weapons for next campaign against Muslims. They had three thousand well-armed fighters divided into three massive columns. The women’s group was led by Hind, Abu Sufyan’s wife who vowed not to mourn the deaths of her father, brother and uncles, and also promised not to sleep with her husband until she had her vengeance against the Muslims. Abu Sufyan trying to convince his wife of his own bravery also promised not to bathe until he defeated Muhammad. Many women decided to come along to encourage their husbands and fathers and watch the battle. Hind, Abu Sufyan’s wife stated â€Å"We will indeed accompany the army and no one can stand in our way or force us back into our homes, if the women were present at the Day of Badr soldiers running away would not have happened.† At the head of each Meccan regiment were men who wanted to see Muhammad dead. Among them were Khalid ibn al-Walid famous Meccan cavalry general who wanted glory and accolades. Abu Sufyan and his brother-in-law Ikhrimah, the son of Abu Jahl were seeking blood to fight for glory. The women made it clear that if their men struck down the enemy they would be embraced and w0uld spread rugs for them. If you turn your backs we will avoid you and we will never come back to sleep with you. (pbs.org) The Prophet instructed fifty archers to protect the Muslims backs and not to move from their posts until they saw the Muslims entering the enemy camp, if the Muslims were being beaten they should still stay at their posts and avoid trying to help so that the enemy could not come behind them. However, the archers left their posts allowing the enemy the chance to get behind them which caused the Muslims to be overwhelmed by the much larger enemy (Qur’an 8:27-28) â€Å"O you who have believed, do not betray Allah and the Messenger or betray your trusts while you know [the consequence]. But when he came to it, he was called, Blessed is whoever is at the fire and whoever is around it. And exalted is Allah, Lord of the worlds.† The Prophet himself got struck by a thrown rock that knocked one of his teeth off and he fell to the ground. He was quickly surrounded by Muslims to protect him from the charging Meccans. The Prophet tried to get up but fell into a pit, Ali and another man lifted him out of the pit. The Muslims suffered about seventy casualties and many others were severely wounded, and the Meccans lost hundreds. However, the Muslims admitted defeat because of high number of casualties and wounded including the prophet with regard to the size of their army . The Meccan women led by Hind enraged by their near defeat began to mutilate and deface the fallen Muslims. They cut off noses and ears and made them ornaments or necklaces moving over dead bodies like ghouls. Hind found Hamza’s dead body, ripped open his chest and chewed on his liver, fulfilling her vow. Hamza was Muhammad’s uncle and the one who killed Abu Jahl, the father of Hind. Hamza was killed by a slave whom Hind promised to set free if he killed Hamza. (Emerick Yahiya) After the battle of Uhud the Muslims position in Medina was precarious and the hypocrites capitalized on this situation to strengthen their position. Most of the tribes were now emboldened since they realize that the Muslims were not invincible. Many times, Muslims who were sent on missions got massacred and this brought about a lot of sadness among surviving compatriots. Muhammad explained the change in their fortunes as God’s way of testing their resolve and sincerity. (Qur’an 2:15 5-156). The Jews who had signed treaties with the Prophet broke the terms of the treaties and they were exiled from Medina. The Jews incited other tribes and Mecca to go to war with Muslims to wipe out Islam. The tribes and Meccans made up an army of about ten thousand fighters to attack the Muslims. The Prophet and other Muslims dug a trench at the south entrance of the city to protect Medina from the menacingly large army attack, since the other side was Mount Uhud and the back was the Jewish fortresses. The army arrived but could not enter the city of Medina so they laid siege for three weeks. This was called the siege of Medina or Battle of the Trench. This was a difficult time for Muslims because their food supply was running out and their Jewish neighbors (Banu Qurayza) had cut the food supply. However, after about three weeks in the cold desert nights the army started feeling weary. One night a raging winter storm befell the army, and the weather was so harsh that they decided to leave. (Emerick Yahiya) CONQUEST of MECCA and PASSING of the PROPHET Despite all the troubles Muslims faced, Islam was steadily growing. In the year 628 c.e the Muslims and the Quraysh signed the treaty of Hudaybiyah, and the Muslims defeated the Jews at the battle of Khaybar. In the year 629 Muhammad led a lesser pilgrimage to Mecca and Khalid ibn Walid converted to Islam. In the year 630 c.e the prophet marched unto Mecca with over ten thousand followers. They faced very little resistance from the Meccans. The prophet and the Muslims destroyed and removed all the idols that filled al Ka’aba and established prayers in the place. Abu Sufyan the last strongest Quraysh leader converted to Islam. (Emerick Yahiya) In the year 632 c.e the prophet went to Mecca with over one hundred thousand followers to perform farewell pilgrimage (hajj). This was to be his last hajj and this was where gave the farewell sermon (address), which reads O People, lend me an attentive ear, for I dont know whether, after this year, I shall ever be amongst you again. Therefore listen to what I am saying to you carefully and TAKE THIS WORDS TO THOSE WHO COULD NOT BE PRESENT HERE TODAY. O People, just as you regard this month, this day, and this city as Sacred, so regard the life and property of every Muslim as a sacred trust. Return the goods entrusted to you to their rightful owners. Hurt no one so that no one may hurt you. Remember that you will indeed meet your LORD, and that HE will indeed reckon your deeds. ALLAH has forbidden you to take usury (Interest), therefore all interest obligation shall henceforth be waived Beware of Satan, for your safety of your religion. He has lost all hope that he will ever be able to lead you astray in big things, so beware of following him in small things. O People, it is true that you have certain rights with regard to your women, but they also have right over you. If they abide by your right then to them belongs the right to be fed and clothed in kindness. Do treat your women well and be kind to them for they are your partners and committed helpers. And it is your right that they do not make friends with any one of whom you do not approve, as well as never to commit adultery. O People, listen to me in earnest, worship ALLAH, say your five daily prayers (Salah), fast during the month of Ramadan, and give your wealth in Zakat. Perform Hajj if you can afford to. You know that every Muslim is the brother of another Muslim. YOU ARE ALL EQUAL. NOBODY HAS SUPERIORITY OVER OTHER EXCEPT BY PIETY AND GOOD ACTION. Remember, one day you will appear before ALLAH and answer for your deeds. So beware, do not astray from the path of righteousness after I am gone. O People, NO PROPHET OR APOSTLE WILL COME AFTER ME AND NO NEW FAITH WILL BE BORN. Reason well, therefore, O People, and understand my words which I convey to you. I leave behind me two things, the QURAN and my example, the SUNNAH and if you follow these you will never go astray. All those who listen to me shall pass on my words to others and those to others again; and may the last ones understand my words better than those who listen to me directly. BE MY WITNESS O ALLAH THAT I HAVE CONVEYED YOUR MESSAGE TO YOUR PEOPLE. After the prophet concluded his final sermons the following qur’anic (ayat) verse was revealed to him (Quran 5:3) â€Å"This day have I perfected your religion for you, completed My Grace upon you, and have chosen Islam for you as your religion.† Muhammad died in the year 632 c.e. after a short illness two years after he conquered Mecca and destroyed the idols in al-Ka’aba. He was buried at Medina in the Mosque (Masjid Nabawi). â€Å"There is no forcing anyone into this way of life. Truth stands clear in the from error† (Qur’an 2:256) Sources Gelvin James L, (2011) The Modern Middle East- A History, Oxford University Press, New York Emerick Yahiya, (2002) The Life and Work of Muhammad, Alpha Books, Indianapolis Britannica Online Encyclopaedia- Muhammad (The Prophet of Islam). Retrieved on September 23, 2012 www.britannica.com/EBchecked/topic/396226/Muhammad PBS-islam: Empire of Faith-Profiles-Muhammad. Retrieved on September 25, 2012 www.pbs.org/empires/islam/profilesMuhammad.html Christian Apologetics and Research Ministry (CARM). Retrieved on September 30, 2012 http://www.carm.org/muhammad Inter-Islam Home. Retrieved on October 12, 2012 www.inter-islam.org/Biographies Mission Islam. Retrieved on October 15, 2012 www.missionislam.com/knowledge/zakat.htm

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