The Navy Commission Program

The Navy Commission Program The Navy Commission Program The naval force commission program has guiding principle that all naval officials are bound to abide.They include,honor,courage and commitment.In respect of state,I will act in high moral way to those I relate with both my friends and follow orders from my supervisors.i will be liable for every one of my activities and I will consistently keep my assertion as I have been taught.i will be careful in serving my kindred residents. Mental fortitude is additionally another basic belief which I have consistently regarded and accept its a worth everybody battling for his nation ought to have.I will safeguard my nation and bolster each strategic is in my line.I will take fearlessness in conveying every one of my obligations anyway requesting or dangerous they may give off an impression of being. Responsibility is a temperance that is obligatory in accomplishing the set goal.Iwill give a valiant effort in filling in as a group with my individual officials since collaboration is the main method of exceeding expectations in day by day activities.I will be commited to serve all individuals with no separation. My principle purpose behind applying for this commission program is an extraordinary energy for serving my nation in the power's ability and particularly naval force. I trust I have all the capabilities that are required for the program. I did well in secondary school particularly in math and sciences. I am a decent swimmer; my stature and weight is in the necessary range, and I have no medical problems. I am the sort of an individual who puts stock in culminating what I do; I am driven by the inclination of accomplishing my set objectives and goals. For this situation, I comprehend that crafted by a maritime official is included and requires a great deal of responsibility. Once in a while, it might call for extraordinary penance particularly if another nation attempts to assault from the waters. Applying all the information and aptitudes I have learned in secondary school and as a scout, I accept, I will convey the best administrations for this Country.

Money in Baseball Research Paper Example | Topics and Well Written Essays - 1500 words - 1

Cash in Baseball - Research Paper Example This was the explanation behind the expansion in the incomes of MLB. To expand the incomes, MLB had marked an arrangement with the eBay’s unit StubHub that allowed individuals to purchase and sell tickets. This had influenced the incomes of MLB and they were being profited in rising incomes (Isidore, â€Å"Baseball near Catching NFL as Top $ Sport†). Different wellsprings of income age that was used by MLB were the alternatives, for example, official site of MLB selling various stocks, tickets and different things through ‘satellite radio broadcasts’, TV game bundles and different choices for income (Isidore, â€Å"Baseball Close To Catching NFL As Top $ Sport†). The radio station at the underlying stage was only with the expectation of complimentary exposure, however as the game turned out to be progressively proficient there were contracts between the radio supporter and the classes. At the underlying stage there were less income produced and it was distinctly at a nearby level from the neighborhood radio stations. Later around the year 1950, Liberty Broadcasting System included National radio stations of the games played in the standard season. The consideration of national radio just as transmissions has helped in the groups in MLB to create more incomes (Haupert, â€Å"The Economic History of Major League Baseball†). The TV was utilized as the hotspot for income. The class had contract with the TV supporter and this turned into the wellspring of income that began from 1946. There has been monstrous increment in the income from this source from 1946 till the present circumstance (Haupert, â€Å"The Economic History of Major League Baseball†). From the establishment esteem MLB earned incomes. They have made their image worth and this aided establishment esteem examination. In the year 1998, the most recent group to join MLB had paid US $130 million to MLB for the benefit (Haupert, â€Å"The Economic History of Major League Baseball†).

Farley Essay Example For Students

Farley Essay Dear Lord, as I falter through this life help me to make more chuckling than tears, administer more joy than anguish, spread more cheer than despair. Never let me become so cool that I neglect to see the miracle according to a kid, or a twinkle according to the matured. Never let me overlook my work is to cheer individuals, fulfill them, make them giggle, cause them to overlook at any rate for a second the disagreeableness in their life. Never let me get accomplishment to the point that I end approaching my Creator in the hour of need, recognizing and saying thanks to Him in the hour of bounty. Furthermore, in my last second may I hear You murmur, When you made my kin grin, you made Me grin. This petition was named The Clowns Prayer which was given at Chris Farleys memorial service by a nearby connection. Before this discourse is finished, you will think about the early long stretches of Chris Farleys life and how he turned out to be such a shocking on-screen character. Also, you wil l be educated on a portion of his most prominent accomplishments. At long last, his dependence on medications and how it prompted his dismal demise. II. First I might want to disclose to you a tad about Chriss early years and how he hit it huge. We will compose a custom paper on Farley explicitly for you for just $16.38 $13.9/page Request now A. He was conceived on February 15, 1964 to Tom and Mary Ann Farley in Madison, 1.He has three siblings named Kevin, John, Tom, and a sister named Barbara. 2. He was a hit at home alongside making others snicker at day camp and furthermore Madisons Edgewood High School. 3. He moved on from Marquette University with a degree in Communications and4. Chris then proceeded to work nearby his Dad at Madison Scotch Oil Company. B. Chris began his acting vocation with a gathering called the Ark Improv Theater gathering. 1. There he concentrated under unbelievable executive Del Close at the Improv Olympic Theater. 2. Different entertainers that concentrated under Close were John Belushi and John Candy. 3. After the Ark Improv Theater, Chris proceeded to learn at Chicagos Second City Theater where he was found by Saturday Night Lives maker Lorne Micheals and was welcomed on to the cast in the 1990-91 season. III. Furthermore, I might want to reveal to you some about the following stages in Chris Farleys life where he turned into an individual from the diverting late night show Saturday Night Live and later went on to the big screen. A. Chris turned into a most loved of the American individuals rapidly with his most mainstream jobs such as:1. Himself as the host of The Chris Farley Show. 2. An over-ardent Chippendales artist close by heart pulsate, Patrick Swayze. 3. A threefold separated from powerful orator that lives in a van somewhere near the stream. B. Despite the fact that despite everything making individuals giggle on Saturday Night Live, Chris at long last began his film vocation. 1. In 1992, Chris featured quickly as a security watch in Waynes World. 2. He additionally featured quickly in different motion pictures, for example, Waynes World 2 (1993), Coneheads (1993), Airheads (1994), and Billy Madison in 1995 where he got little compensation for his quality. 3. He at that point left Saturday Night Live in the 1994-95 season alongside a couple of other well known cast individuals to chip away at his film profession. 4. His first significant film was Tommy Boy (1995) which he featured close by past S.N.L part and long time companion David Spade. Farley netted around 10 million for this film. This film was immediately viewed as an exemplary among the numerous fans so the pair chose to dispatch another extraordinary film, Black Sheep (1996). .ud9c18c57c0cd03ff73b12a3e27abb540 , .ud9c18c57c0cd03ff73b12a3e27abb540 .postImageUrl , .ud9c18c57c0cd03ff73b12a3e27abb540 .focused content territory { min-tallness: 80px; position: relative; } .ud9c18c57c0cd03ff73b12a3e27abb540 , .ud9c18c57c0cd03ff73b12a3e27abb540:hover , .ud9c18c57c0cd03ff73b12a3e27abb540:visited , .ud9c18c57c0cd03ff73b12a3e27abb540:active { border:0!important; } .ud9c18c57c0cd03ff73b12a3e27abb540 .clearfix:after { content: ; show: table; clear: both; } .ud9c18c57c0cd03ff73b12a3e27abb540 { show: square; change: foundation shading 250ms; webkit-progress: foundation shading 250ms; width: 100%; darkness: 1; change: murkiness 250ms; webkit-change: haziness 250ms; foundation shading: #95A5A6; } .ud9c18c57c0cd03ff73b12a3e27abb540:active , .ud9c18c57c0cd03ff73b12a3e27abb540:hover { obscurity: 1; progress: mistiness 250ms; webkit-change: haziness 250ms; foundation shading: #2C3E50; } .ud9c18c57c0cd03ff73b12a3e27abb540 .focused content zone { width: 100%; position: relative ; } .ud9c18c57c0cd03ff73b12a3e27abb540 .ctaText { outskirt base: 0 strong #fff; shading: #2980B9; text dimension: 16px; textual style weight: intense; edge: 0; cushioning: 0; content design: underline; } .ud9c18c57c0cd03ff73b12a3e27abb540 .postTitle { shading: #FFFFFF; text dimension: 16px; text style weight: 600; edge: 0; cushioning: 0; width: 100%; } .ud9c18c57c0cd03ff73b12a3e27abb540 .ctaButton { foundation shading: #7F8C8D!important; shading: #2980B9; fringe: none; fringe sweep: 3px; box-shadow: none; text dimension: 14px; textual style weight: striking; line-stature: 26px; moz-outskirt span: 3px; content adjust: focus; content enhancement: none; content shadow: none; width: 80px; min-tallness: 80px; foundation: url(https://artscolumbia.org/wp-content/modules/intelly-related-posts/resources/pictures/straightforward arrow.png)no-rehash; position: outright; right: 0; top: 0; } .ud9c18c57c0cd03ff73b12a3e27abb540:hover .ctaButton { foundation shading: #34495E!important; } .ud9c18c57 c0cd03ff73b12a3e27abb540 .focused content { show: table; stature: 80px; cushioning left: 18px; top: 0; } .ud9c18c57c0cd03ff73b12a3e27abb540-content { show: table-cell; edge: 0; cushioning: 0; cushioning right: 108px; position: relative; vertical-adjust: center; width: 100%; } .ud9c18c57c0cd03ff73b12a3e27abb540:after { content: ; show: square; clear: both; } READ: Spring Awakening at the University of Illinois at Urbana †Champaign Essay5. He at that point went solo in his next film, Beverly Hills Ninja (1996), where he netted his second biggest check of roughly 6 million dollars. 6. After Beverly Hills Ninja, Chris proceeded to star quickly in Dirty Work (1998) and furthermore assumed a job close by Friends hotshot, Matthew Perry in Almost Heroes (1998). Farleys vocation, and his life, abrupt stopped because of his long time chronic drug use. IV. At last, on December 18, 1997, Christopher Crosby Farley was articulated dead in hisChicago loft because of an overdose of heroin and opium. A. Chris, much like his guide John Belushi, had a weight and medication issue. 1. Chris remained at 5 feet 9 inches. His Father was assessed to weigh around 600Pounds so you can see where he got his weight. In spite of the fact that he got giggled at commonly due to his weight, he utilized this issue to help humor the crowd. 2. In spite of the fact that he was an exceptionally cherishing and enthusiastic man, his feelings blended in with the giggles caused him to become involved with drugs. 3. His old buddies attempted to help him by sending him to health improvement plans and furthermore sedate recovery places. This worked for a little while yet each time he recovered financially, the issues began once more. 4. Along these lines, the life of an incredible man and legend in my eyes, reached a conclusion atthe youthful age of 33, much the same as his golden calf John Belushi. Numerous individuals accept that the life of a superstar is only distinction and fortune. Chris Farley was at the highest point of his calling since the time he was youthful, while he was on the scandalous late night show Saturday Night Live, and furthermore in the spotlight on the big screen. His battles with weight and medications at last defeated him. I accept that individuals ought to recollect Chris similar to the lord of satire another big name that had a chronic drug use. David Spade said all that needed to be said in a 1998 issue of Rolling Stone, I would simply like individuals to recall Chris as a person who attempted to satisfy everybody in a world that is so difficult and merciless. What's more, as it were, attempting to fulfill everybody cost him his life, since he thoroughly took care of every other person and not for himself. Chris made a decent attempt to get everybody to like him. In the mean time, the reality of the situation was that everybody previously preferred him to an extreme. Catalog:

Art enhances our understanding of Reality

Regardless of whether it is dramatization, works of art, writing, or music that they experience individuals value them as shallow practices surviving for delight. In any case, this idea is not right. The media is a plenty loaded with different expressions serving to speak to marvels that happen, all things considered. Through their works, specialists pass on their own nterpretations of the predominant issues of society.Thus, the crowd is given a clear outline of reality in context of an omniscient position. A famous American writer from the twentieth century, John Steinbeck articulated, â€Å"l loathe cameras. They are such a great amount of sure than I am tied in with everything. † There was a period in history when society stopped to create, called the Middle Ages. Individuals in this time choked in the equivalent, unending arrangement of which social classes were vile. In addition to the fact that groups were dealt with in an unexpected way, yet in addition those mpotent in the public arena had not many rights.Thus, in the accompanying time frame, called the Renaissance, specialists wandered from vision. Rather, they slanted to every day parts of life as self-ruling people, wanting to surrender the old ways. One notable fgure is Leonardo da Vinci, who impacted his counterparts with his works of humanistic examinations. Da Vinci communicated in his specialties the will to find oneself and conceivably discover his way of life as a person. Much the same as Da Vinci who spread the information on humankind through his specialties, in odays society, numerous inventive craftsmen make works with specific intends to pass on the status quo.For model, our reality is falling apart because of abuse of nature. Most of the populace squander characteristic assets, for example, metals, trees, and different recyclables also. Dampened, a popular hip-bounce craftsman, T. l. , was resolved to demonstrate the world's have to spare trees and essentialness of reusing. Regard less, â€Å"Paper Trail†, a self-representation sorted out with paper shreds, had the option to effectively exhibit the gravity of ecological issues to the individuals, extraordinarily his fans. Accordingly, significant works, for example, the fine art of T. . ‘s, can intimate the progressing issues in our general public. Right up 'til the present time, practices of craftsmanship clearly delineate the ‘reality by including the human detects - Literature for the perusers, artworks for the watchers, and music for the audience members.

Nursing beliefs/skills Essay

As my vocation through nursing school has advanced in the course of the last more than two years I have been honored with the chance to take an interest in a huge number of clinical encounters. These clinical encounters have given me important hands-on information to encourage with my coursework in the study hall. I accept that experiential learning is one of the principle parts of nursing school which recognizes it from different majors. Through my clinical pivots I had the option to secure many hours in the clinical setting, permitting me to turn out to be more ready for life after graduation. During my time in the study hall I learned important abilities expected to exceed expectations in the nursing calling, however without my experiential learning I would not have had the chance to consummate these aptitudes. Going through a few hundred hours in the clinical setting gave personal time to practice and ace these aptitudes to a level suitable for an alumni nurture. As future development practice nurture I am presently, like never before previously, mindful of the amount I despite everything need to learn. I accept that learning isn't only the flitting procurement of information or abilities yet possibly effectively happens when information and aptitudes become sharpened and show itself in each part of training. Taking a gander at my future as advance practice nurture, I trust that I will consistently have a basic consciousness of all the distinctive job works in an assortment of conditions. I’ve discovered that various individuals are acceptable at various things so as I plan for my own propelled vocation, I attempt to discover for each extraordinary development practice job, a kindred expert whom I may think about the embodiment of that particular job. From one NP, I may figure out how to be a specialist clinician who consistently coordinates information into training and from the following, increasingly about how to be a promoter for a specific populace. From the enthusiastic, vivacious physician’s colleague, I may figure out how to introduce a training issue so as to impact clinical practice changes for the improvement of patient consideration. From the expressive teaming up doctor I may discover that being a specialist doesn't imply that I know all the appropriate responses and that the best patient consideration really spills out of a group which cooperates to help their patients.

A Marketing Plan Pricing Strategy For Blue Mountain Spring Water - 275 Words

A Marketing Plan: Pricing Strategy For Blue Mountain Spring Water (Essay Sample) Content: Pricing strategy for Blue Mountain Spring Water Name Course Institution Professor Date Pricing strategy for Blue Mountain Spring Water A marketing plan is simply a written document that outlines the company’s strategies for advertising and marketing for a future financial year. It can be for the next year or for a given period, the given time is actually decided by the shareholders of the business firm. Blue Spring Water Company is a company that deals with the bottling of safe clean water for drinking. The company has outlined a three year with the main objective of raising funds for major developments in marketing and reporting to the employees regarding the time concern of the company (Yan, 2010). This essay seeks to explore pricing strategy as outlined within the marketing plan of Blue Mountain Spring Water. The company will employ a marketing strategy that will enable it to grow at the same time to remain a force to reckon with in the market. The strategy will aim at making profits while offsetting expenses and having something to oversee it during times of economic hardships. The four objectives of pricing strategy include, premium pricing whereby a company can decide to charge a higher price compared to its competitors. The objective of this is to establish a brand that is considered luxurious. The other strategy is penetration strategy, this involves charging less price compared to the competitors by a company that is new to the market. The objective is to gain market share because consumers will opt to buy the cheaper substitute. ...

How to Write My Term Paper Cheaply

How to Write My Term Paper CheaplyIn order to write my term paper I needed to cut some corners. When you're writing a term paper, a rough draft is best and it's never too late to do it. Here are some ways to cut corners while writing my term paper.Excel - You can get Excel from many different places on the web. I would recommend using Excel because it's easy to use and it saves you time. Excel makes working with formulas simple and easy. You can also edit the formulas and get results back the way you want them.Google Docs - My preference for working on a paper is using a Google Docs. It's easy to set up and you don't have to worry about formatting a page for your term paper. You can start a presentation just by typing in the title of the page. Your presenter will be able to open up and read the document easily.Business Card Generator - It may sound odd but I really do like the business card generator. It's a nice way to get a nice looking business card. The only downside is that you have to keep buying new business cards. I still need to buy several business cards for different groups of people and I still haven't spent all my money!Grammar Checker - I don't know how many times I've heard someone say they're tired of writing their term paper and they're just going to throw it in the trash can. I'm not saying you shouldn't try and throw your term paper away, I'm saying that it can save you time if you make sure to use it. You can get a grammar checker online or at your local library and just go through the document.Using Text To Speech - You can get a nice sounding voice for your term paper by going to your computer and clicking on the computer and sayings then you can download the voice file for your term paper. It doesn't take a lot of space so you can send out as many as you want. You can also get a professional sounding speaker for a little more.Now that you know what some of the things you can do to cut some corners while writing your term paper, you can st art writing your paper. It might even help you with your term paper, if you take some of these ideas into consideration.

Patient information and presenting complaints - Free Essay Example

Sample details Pages: 25 Words: 7495 Downloads: 1 Date added: 2017/06/26 Category Health Essay Type Essay any type Did you like this example? 1.0 CASE SUMMARY 1.1 Patient information and presenting complaints SAR, a 54-year-old female with weight of 54kg and height of 160cm was referred to the hospital by her GP due to shortness of breath which was not relieved by taking inhaler, minimum cough with yellowish sputum, abdominal pain and mild diarrhoea. Her shortness of breath had been on and off for the past 1 week and the condition was deteriorating on the day of admission. 1.2 Relevant history SAR is a non-smoker and a non-alcoholic housewife. She has had bronchial asthma since childhood. Her siblings and children were found to have family history of bronchial asthma as well. The patient has been taking inhaled salbutamol 200 µg 1 puff when required as reliever and inhaled budesonide 200 µg 2puffs bd as preventer for umpteen years. Besides that, SAR also has medical history of hypertension, diabetes mellitus and ischaemic heart disease (IHD) for 10 years. She has no relevant family history for these illnesses. For the past few years, SAR has been taking rosuvastatin 20mg at night, fenofibrate 160mg OD and ezetimibe 10mg OD for dyslipidaemia, gliclazide 60mg BD and rosiglitazone 4mg OD for diabetes mellitus, losartan 50mg OD for hypertension, ticlopidine hydrochloride 250mg OD for prophylaxis against major ischaemic events and famotidine 20mg OD to prevent gastrointestinal ulceration due to the use of anti-platelet agent. Don’t waste time! Our writers will create an original "Patient information and presenting complaints" essay for you Create order 1.3 Clinical data On examination upon admission, SARs blood pressure and pulse rate were recorded as 111/80 mmHg and 111bpm respectively. Her respiratory rate was normal (16 breaths/min). Her SpO2 measurement was 98% and it showed decreased high flow mask. Her DXT blood glucose test revealed that her random blood glucose level was abnormally high (21.6mmol/L). From the doctors systemic enquiry, SARs ankles were slightly swollen and her respiratory system showed prolonged minimal bibasal crept and rhonchi. Also, SARs chest X-ray showed shadowing in the lower zone of her right lung. The renal function tests gave results of high urea and elevated creatinine levels of 16.3mmol/L and 270 µmol/L respectively. Creatinine clearance derived from Cockcroft and Gault formula is 17ml/min which indicates that the patient has severe renal impairment. The liver function tests revealed a mild decrease in albumin concentration and an increase in the plasma globulin. On the other hand, the haematological tests show ed low red blood cell count (3.41012/L), low haemoglobin count (9.4g/dL), high platelet count (410109/L), high white blood cell count (17.1109/L), high neutrophil count (16.4109/L) and low lymphocyte count (0.5109/L), whereas cardiac marker tests showed abnormally high counts in creatine kinase (156IU/L) and lactate dehydrogenase (627IU/L). 1.4 Diagnosis and Management Plan Based on the patients symptoms, medical history, physical examinations, and laboratory tests, SAR was diagnosed with chronic heart failure (CHF), acute exacerbation of bronchial asthma (AEBA) secondary to pneumonia and uncontrolled diabetes mellitus. Her doctor developed therapeutic plans which included anti-asthmatic drugs and antibiotics, and ordered further investigations such as SpO2 and PEFR. Besides that, her doctor also added diuretic to her ACEI therapy and restrict her fluid intake to not more than 800cc/day. Her uncontrolled diabetes mellitus was under monitoring of DXT blood glucose test 4 hourly and she was referred to dietician for diabetic diet counselling. 1.5 Ward medication Throughout the 3days in hospital, Sarah was being prescribed with medications as listed below: Drug route Dose frequency Start date Stop date Indication/ Comments T. Gliclazide (Diamicron ® MR) 60mg bd Day 1 Diabetes mellitus T.Rosiglitazone 4mg od Day 1 Diabetes mellitus T.Rosuvastatin 20mg nocte Day 1 Dyslipidaemia T.Fenofibrate 160mg od Day 1 Dyslipidaemia T.Ezetimibe 10mg od Day 1 Dyslipidaemia T.Lovastatin 20mg nocte Day 1 Dyslipidaemia T.Ticlopidine HCL 250mg od Day 1 Prophylaxis against ischaemic T.Losartan 50mg od Day 1 CHF T.Famotidine 20mg od Day 1 Prevent GI upset Neb ipratroupium bromide 500 µg, salbutamol 5mg, normal saline 2:1:2 qqh Day 1 Day 3 AEBA IV Hydrocortisone 100mg stat Day 1 Day 1 AEBA Neb Salbutamol 1 puff prn Day 1 AEBA/chronic asthma MDI Budesonide 200mcg 2 puffs bd Day 1 AEBA/chronic asthma T. Azitromycin 500mg od Day 1 Day 3 Pneumonia IV Ceftriaxone 2g stat Day 1 Day 1 Pneumonia IV Furosemide 40mg bd Day 1 Day 2 CHF S/C Actrapid 5? , 10? Day 1 Day 2 Diabetes mellitus T. Prednisolone 30mg od Day 2 AEBA MDI Beclomethasone 200mcg 2puffs tds Day 2 Chronic asthma T.Cefuroxime 250mg bd Day 2 Pneumonia T. Furosemide 40mg od Day 2 CHF S/C Mixtard 30/10? Day 3 Diabetes mellitus 1.6 Clinical Progress and Pharmaceutical Care Issues On the first day of admission, the patients past medication history was confirmed by appropriate patient interview and her family members were being advised to bring SARs home medication to ensure that the appropriate medications were continued and prescribed. From the interview, dust was found to be the chief precipitating factor. The patient was on appropriate drugs (nebulised ipratropium bromide 0.5mg and nebulised salbutamol 5mg in normal saline 4 hourly, IV hydrocortisone 100mg stat) for acute management of severe asthma as according to guidelines and eventually her SOB was relieved.2-3 However, she was prescribed with oral prednisolone at dose as low as 30mg od for acute asthma, it should be suggested to increase prednisolone dose to 40-50mg daily as according to evidence-based guidelines to achieve maximal effects.2-3 Another pharmaceutical care issue is regarding the patients poor inhaler technique. Thus, the pharmacist educated and assessed SAR on her inhaler technique sin ce day 1. Appropriate antibiotics indicated for pneumonia which included IV ceftriaxone 2g stat and oral azitromycin 500mg od were initiated upon admission. Oral cefuroxime 250mg bd was added to the drug regimen on day 2 after stopping IV ceftriaxone 2g on the first day. Therefore, signs of recovery and WBC count were monitored regularly and completion of antibiotic course was ensured. In addition to that, vaccinations against pneumococcal infection and influenza should be strongly recommended in this asthmatic patient.2-3,5-8 Co-administration of high dose IV furosemide (40mg bd) and corticosteroids can increase the risk of hypokalaemia, therefore SAR should be started on potassium chloride 600mg bd which is an appropriate dose for renal insufficiency patient to avoid the potential risk.1 Besides that, potassium level of SAR should also be closely monitored during the administration of potassium chloride. The doctor added lovastatin 20mg at night to her existing triple the rapy of dyslipidaemia (rosuvastatin, ezetimibe, fenofibrate). Rosuvastatin should be avoided if patients creatinine clearance is less than 30ml/min.1 Due to its same mechanism of action as lovastatin and its contraindication in patient with severe renal impairment, rosuvastatin should be withdrawn from the drug regimen. Practically, a comprehensive lipid profile of SAR should be established and monitored in order to choose the best combination of lipid lowering agents to improve the individual components of lipid profile. Combination therapy of ezetimibe and lovastatin is considered more appropriate as concurrent use of fenofibrate and statin may potentiate myopathy. Therefore, fenofibrate and rosuvastatin should not be continued. Liver function should be monitored to avoid the risk of hepatotoxicity. SAR was diagnosed with uncontrolled diabetes mellitus which means her blood glucose level was not adequately controlled with concurrent therapy of gliclazide and rosiglitazone. Her random blood glucose level was fluctuating throughout day 1 (24.9mmol/L, 14.2mmol/L, 7.3mmol/L and 14.7mmol/L). Targets for blood glucose levels should be ideally maintained between 4 and 7mmol/L pre-meal and 9mmol/L post-meal provided there is no significant hypoglycaemia, and HbA1c of ?7% is a more practical target compared to HbA1c of 6.5%.1,4 SAR was started on insulin injections to lower and control her blood glucose level during hospital admission. Type 2 diabetes mellitus management guideline recommends the addition of insulin to the two oral hypoglycaemic agents after the dual oral therapy fails.4 However, rosiglitazone is contraindicated in patient with CHF and not recommended in patient with history of IHD; therefore the use of rosiglitazone should be reviewed.1,5-6 The most appropriate action is to withdraw rosiglitazone from the drug regimen and close monitoring of patients random blood glucose and glycosylated haemoglobin (HbA1c) should be carried out to confirm the eff ectiveness of the combination therapy (gliclazide and insulin) in controlling the blood glucose level. Although metformin is the first line treatment of Type 2 diabetes mellitus, it is contraindicated in Type 2 diabetic patients undergoing treatment with CHF and there is increased risk of lactic acidosis in severe renal impairment patient, therefore addition of metformin should be avoided in this case.1,4 During the hospital admission, SAR was educated on the proper technique of insulin injection. In this case, the decreased plasma levels of haemoglobin and red blood cells in the heart failure patient were most likely exacerbated by the administration of rosiglitazone.1 If the anaemia problem is not improved upon the withdrawal of rosiglitazone, erythropoietin and iron therapy can be considered.9 On day 2, SAR was feeling much more comfortable and had not complaint of SOB. However, SARs maintenance management of asthma was found to be not conformed to the asthma guidelines.2-3 Sh e was prescribed with unacceptable high dose of corticosteroids (MDI beclomethasone 200 µg 2 puffs tds) in addition to her current steroid regimen (MDI budesonide 200 µg 2 puffs bd and oral prednisolone 30mg od). SAR was at potential high risk of experiencing considerable side effects such as diabetes, oesteoporosis, Cushing syndrome with moon face, striae, acne, abdominal distension and other profound effects on musculoskeletal, neuropsychiatric and ophthalmic systems as a result of overdosage of corticosteroids.1 Oropharyngeal side effects such as candidiasis are also more common at high dose of inhaled steroids, but can be minimized if the patient rinse the mouth with water after inhalation. It should be recommended to add the long acting beta agonist (LABA) to the inhaled corticosteroids (ICS) treatment instead of initiating SAR on high dose steroid (2000 µg). Combination inhaler of formoterol and budesonide (Symbicort 200/6 Turbohaler ® 2 puffs bd) should be given and c ontrol of asthma need to be continuing assessed.2-3 If LABA is proved to be not effective, addition of 4th agent (leukotriene receptor antagonist, theophylline or oral beta agonist) can be considered.2 When SAR showed recovery of leg swelling, furosemide was given orally instead of intravenously with reduced frequency and total daily dose. On day 3, SAR was arranged to be discharged. The pharmacist should review the appropriateness of discharged medication by checking discharged prescriptions against ward medication chart and ensure all information relevant to primary care referrals are included. In addition to that, the pharmacist should also reiterate and reinforce the importance of patient compliance and follow-up reviews, counsel on indications, doses and possible adverse effects of each discharged medication, and rechecked SARs inhaler and insulin injection techniques prior discharged. Asthma education includes advice to avoid trigger factors, including caution with NSAIDs a nd avoidance of dust exposure. Greater attention should be paid to inhaler technique as poor technique leading to failure of treatment. SAR should be educated on the use of peak flow meters and advised to monitor and record her own PEFR at home. A written personalised asthma action plans should be designed for SAR prior discharged. Diabetic counselling should emphasize on proper insulin injection techniques and healthy lifestyle modifications. SAR needs to be made aware of the signs of hypoglycaemia and hyperglycaemia and how to response to them. Polypharmacy may adversely affect compliance with prescribed drug therapy, therefore SAR should be taught not to mix up her medicines by using daily pill box and her family member should also be advised to supervise her on medicine taking. 2.0 PHARMACOLOGICAL BASIS OF DRUG THERAPY 2.1 Disease background 2.1.1 Asthma Asthma is a common chronic inflammatory condition of the lung airways affecting 5-10% of the population and appears to be on the increase.5 It is especially prevalent in children, but also has a high incidence in more elderly patient. Asthma mortality is approximately 1500 per annum in the UK and costs in the region of  £2000 million per year in health and other costs.2-3,6 Symptoms of asthma are recurrent episodes of dyspnoea, chest tightness, cough and wheeze (particularly at night or early in the morning) caused by reversible airway obstruction. Three factors contribute to airway narrowing: bronchoconstriction triggered by airway hyperresponsiveness to a wide range of stimuli; mucosal swelling/inflammation caused by mast cell, activated T lymphocytes, macrophages, eosinophils degranulation resulting in the release of inflammatory mediators; smooth muscle hypertrophy, excessive mucus production and airway plugging.7 There is no single satisfactory diagnostic test for all asthma tic patients. The useful tests for airway function abnormalities include the force expiratory volume (FEV1), force vital capacity (FVC) and peak expiratory flow rate (PEFR). The diagnosis is based on demonstration of a greater than 15% improvement in FEV1 or PEFR following the inhalation of a bronchodilator.2,3,6 Repeated pre and post-bronchodilator readings taken at various times of the day is necessary. The FEV1 is usually expressed as the percentage of total volume of air exhaled and is reported as the FEV1/FVC ratio. The ratio is a useful and highly reproducible measure of lungs capabilities. Normal individuals can exhale at least 75% of their total capacity in 1 second. A decrease in FEV1/FVC indicates airway obstruction. 2.1.2 Community-acquired pneumonia Pneumonia is defined as inflammation of the alveoli as opposed to the bronchi and of infective origin. It presents as an acute illness clinically characterized by the presence of cough, purulent sputum, breathlessness, fever and pleuritic chest pains together with physical signs or radiological changes compatible with consolidation of the lung, a pathological process in which the alveoli are filled with bacteria, white blood cells and inflammatory exudates. The incidence of community acquired pneumonia (CAP) reported annum in UK is 5-11 per 1000 adult population, with mortality rate varies between 5.7% and 14% (patients hospitalised with CAP).8 Streptococcus pneumonia is the commonest cause, followed by Haemophilus influenzae and Mycoplasma penumoniae.7 2.1.3 Congestive cardiac failure Congestive cardiac failure occurs when the heart fails to pump an adequate cardiac output to meet the metabolic demands of the body. It is a common condition with poor prognosis (82% of patients dying within 6 years of diagnosis) and affects quality of life in the form of breathlessness, fatigue and oedema.6,7 The common underlying causes of cardiac failure are coronary artery disease and hypertension. Defects in left ventricular filling and/or emptying causes inadequate perfusion, venous congestion and disturbed water and electrolyte balance. In chronic cardiac failure, the maladaptive body compensatory mechanism secondary physiological effects contribute to the progressive nature of the disease.6 2.1.4 Diabetes mellitus Diabetes mellitus is a heterogenous group of disorders characterised by chronic hyperglycaemia due to relative insulin deficiency and/or resistance. It can be classified as either Type 1 or Type 2. In Type 1, there is an inability to produce insulin and is generally associated with early age onset. Decreased insulin production and/or reduced insulin sensitivity, maturity onset and strong correlation with obesity are characteristics of Type 2 diabetes. Diabetes affects 1.4 million people in the UK, over 75% of them have Type 2 diabetes.6 It is usually irreversible and if not adequately managed, its late complications can result in reduced life expectancy and considerable uptake of health resources. 2.2 Drug pharmacology 2.2.1 Treatment for asthma 2.2.1.1Beta-adrenoceptor agonists (e.g. salbutamol, terbutaline) These short-acting selective ?2 agonists (SABA) are the first line agents in the management of asthma and are also known as relievers. The selective ?2 agonists act on ?2 aderenoceptors on the bronchial smooth muscle to increase cyclic adenosine monophosphate (cAMP) leading to rapid bronchodilation and reversal of the bronchospasm associated with the early phase of asthmatic attack.5 Such treatment is very effective in relieving symptoms but does little for the underlying inflammatory nature of the disease. ?2 agonists should be initiated ‘when required as prolonged use may lead to receptor down regulation renders them less effective.5-6 Compared to SABA, long-acting beta-adrenoceptor agonists (e.g. salmeterol, formoterol) have slower rate of onset and their intrinsic lipophilic properties render them to be retained near the receptor for a prolonged period (12hours), which means that they cause prolonged bronchodilation. 2.2.1.2 Muscarinic receptor antagonists (e.g. ipratropium) Ipratropium blocks parasympathetic-mediated bronchoconstriction by competitively inhibiting muscarinic M3 receptors in bronchial smooth muscle.1,5-6 It has slower onset of action than ?2 agonists but last longer. 2.2.1.3 Inhaled corticosteroids (ICS; e.g. beclomethasone, budesonide) and oral prednisolone These agents are used to prevent asthmatic attacks by reducing airway inflmmation. They exert their anti-inflammatory actions via activation of intracellular receptors, leading to altered gene transcription. This results in decreased cytokine production and the synthesis of lipocortin leading to phospholipase A2 inhibition, and the inhibition of leukotriene and prostaglandins.5 Candidiasis occurs as common side effects with inhalation and systemic steroid effects such as adrenal suppression and osteoporosis, occur with high dose inhalation or oral dosing. 2.2.2 Treatment for pneumonia Antiobiotic treatment is appropriate with amoxicillin being used as first choice agent for mild, community-acquired infections. Depending on response and the strain of bacteria, other antibiotic agents can be used. Two groups of antibiotics which were given to the patient in this case scenario will be discussed here. 2.2.2.1 Cephalosporins (e.g. cefuroxime, ceftriaxone) Both ceftriaxone and cefuroxime are broad spectrum bactericidal antibiotics belong to cephalosporins group. They inhibit the synthesis of bacterial cell wall by binding to specific penicillin-binding proteins and ultimately leading to cell lysis. Second generation cefuroxime is beta-lactamase resistant and active against Gram-negative bacteria such as Haemophilus influenzae and Klebsiella pneumoniae. Being third generation cephalosporin, ceftriaxone display high beta–lactamase resistance and enhanced activity against Gram-negative pathogens (including Pseudomonas Aeruginosa), but it has relatively poor activity against Gram-positive organisms and anaerobes.1,5-6 2.2.2.2 Maclolides (e.g. azithromycin, erythromycin, clarithromycin) Maclolides prevent protein synthesis by inhibiting the translocation movement of the bacterial ribosome along the mRNA, resulting in bacteriostatic actions. Azithromycin has slightly less activity than erythromycin against Gram-positive organisms but possesses enhanced activity against Gram-negative bacteria including Haemophilus influenza. 2.2.3 Treatment for chronic cardiac failure 2.2.3.1 Loop diuretics (e.g. furosemide) Diuretics are the mainstay of the management of heart failure and provide rapid symptomatic relief of pulmonary and peripheral oedemia.5,6,9 Loop diuretics are indicated in majority of symptomatic patients and they work by inhibiting Na+/K+/2Cl- transporter in the ascending limb of the loop of Henle, inhibiting the establishment of a hyperosmotic interstitium and thus reducing the production of concentrated urine in kidney, leading to profuse dieresis.5-6 2.2.3.2 Angiotensin II receptor antagonists (e.g. losartan, candesartan, valsartan) These agents block the action of angiotensin II at the AT1 receptor, which will also reduce the stimulation of aldosterone release. Therefore AT1 receptor antagonists can be used as an alternative in patients suffering from a cough secondary to ACE inhibitors. 2.2.4 Treatment for Type II diabetes mellitus 2.2.4.1 Sulphonylureas (e.g. Gliclazide, glibenclamide, glipizide) The sulphonylureas have two main actions: increase basal and stimulated insulin secretion and reduce peripheral resistance to insulin action. They bind to receptors associated with voltage dependent KATP channels on the surface of pancreatic beta cell, causing channel closure which facilitates calcium entry into the cell and leads to insulin release. Sulphonylureas are considered in Type II diabetes patients who are intolerant to metformin, not contraindicated and not overweight. 2.2.4.2 Thiazolidinediones (e.g. rosiglitazone, pioglitazone) These new agents are ‘insulin sensitisers which act as nuclear peroxisome proliferator-activated receptor-gamma (PPAR-?) agonist. They work by enhancing insulin action and promoting glucose utilization in peripheral tissue, and so reduce insulin resistance. Thiazolidinediones is known to be associated with oedema and increased cardiovascular risks, therefore these agents should be avoided in patients with heart failure.1,4,6 3.0 EVIDENCE FORTREATMENT OF CONDITIONS 3.1 Asthma 3.1.1 Evidence for the use of oral prednisolone and IV hydrocortisone in the management of AEBA There are mounting evidences suggesting that systemic corticosteroids effectively influence the airway oedema and mucus plugging associated with acute asthma by suppressing the components of inflammation, including the release of adhesion molecules, airway permeability and production of cytokines.10-12 A randomised trial involving 88 patients (aged 15-70years) with AEBA reported the significant efficacy of oral prednisolone (40mg daily for 7 days) in improving FEV1 and FVC at values of 68 ±45.3% and 53.4 ±46.5% respectively (P=0.04) in prednisolone-treated group.13 A Cochrane meta-analysis involving six trials recruiting 374 acute asthmatic exacerbation patients determined the early use of systemic corticosteroids significantly reduced the number of relapses to additional care, hospitalisation and use of short-acting ?2-agonist without increasing side effects, regardless of the routes of administration studied (oral/intramuscular/intravenous) and choice of agents.14 3.1.2 Evidence for the use of inhaled ipratropium bromide in the management of AEBA A double-blind, randomised controlled trials recruiting 180 patients with AEBA admitted to emergency department showed that ipratropium had beneficial effects in improving pulmonary function, with a 20.5% increment in PEF (p=0.02) and a 48.1% greater improvements in FEV1 (p=0.0001) compared to those given ?2-agonists alone. Ipratropium also demonstrated a 49% reduction in the risk of hospital admission.15 A more recent meta-analysis incorporating thirty-two double-blind, randomised controlled trials including 3611 patients with moderate to severe exacerbations of asthma also showed the benefits of combination treatment of nebuliser ?2-agonists and anti-muscarinic in reducing hospital admissions (relative risk 0.68,p=0.002) and in producing a significant increase in lung function parameters in AEBA patients (standard mean difference -0.36, p=0.00001).16 Another pooled analysis of three multicenter, double-blind, randomised controlled studies also showed that combination therapy of i pratropium bromide and salbutamol for the treatment of AEBA had decreased risk of the need for additional treatment (relative risk=0.92), asthma exacerbation (relative risk=0.84) and hospitalisation (relative risk=0.80).17 3.1.3 Evidence for addition of LABA to ICS in the management of asthma Symbicort Maintenance and Reliever Therapy (SMART) studies demonstrated the combined use of formoterol/budesonide contributes to a greater reduction in risks of exacerbations, improved lungs performance and better control of asthma than high dose of ICS with SABA.18-22 These studies also reported the advantage of this approach in terms of patient compliance as it allows the use of single inhaler for both rescue and controller therapy, and reductions in healthcare costs.18-22 A large double-blind, randomised trial reported that there was a significant 21-39% reduction of severe exacerbations in asthmatic patients treated with SMART therapy compared with high dose budesonide plus SABA.23 A meta-analysis involving 30 trials with 9509 patients showed that the use of combination inhaler (formoterol/beclomethasone 400mcg) resulted in greater improvement in FEV1, in the use of rescue SABA and in the symptom-free days compared to a higher dose of ICS (800-1000mcg/day).24 Another double-bli nd randomised trial investigating the effect of combination budesonide and formoterol as reliever therapy for 3394 patients who were assigned budesonide plus formoterol for maintenance therapy showed that the time to first severe exacerbation was significantly longer in as needed budesonide/formoterol group compared to as needed terbutaline group (p=0.0051). The other finding of the study is the significant lower rate of severe exacerbation for as needed budesonide/formoterol versus as needed terbutaline group (0.19 vs 0.37, p0.0001).25 Chung et al. (2009) reported that addition of LABA may potentiate the anti-inflammatory properties of ICS as addition of formoterol to budesonide resulted in 63% reduction in severe exacerbation rates.26 Other findings of the study are local and systemic side effects of ICS become more frequent when used alone at doses above 800mcg/day, and the increased efficacy of combination with formoterol was achieved with lower dose of budesonide than was requi red in the budesonide group..26 3.2 Community-acquired pneumonia 3.2.1 Evidence use of combination therapy of second and/or third generation cephalosporins and macrolide in the management of pneumonia A multicenter, randomised trial investigated the efficacy of IV ceftriaxone 2g for 1 day followed by oral cefuroxime 500mg bd in the adult pneumonia treatment. The sequential therapy in combination with a macrolide achieved 90% of clinical success, 85% of overall bacteriologic clearance with 100% eradication of S.pneumoniae after 5-7days of treatment.27 An open label, prospective study involving 603 patients demonstrated that adding azithromycin (500mg od for 3days) to IV ceftriaxone 1g/day in the treatment of community-acquired pneumonia resulted in shorter hospital stay (7.3days vs 9.4days) and a significant lower mortality rate (3.7% vs 7.3%) than adding clarithromycin.28 Lack of randomisation and no blinding of evaluators may become the major limitations of this study; however the effectiveness of macrolide in addition to cephalosporins empirical therapy in treating pneumonia is unquestionable. 3.3 Chronic heart failure 3.3.1 Evidence use of loop diuretic in the management of chronic heart failure (CHF) A meta-analysis of 18 randomised controlled trials concluded that diuretics significantly lowered the mortality rate (odds ratio (OR) 0.25, P=0.03) and reduced hospital admissions for worsening heart failure (OR 0.31, P=0.001) in patients with CHF compared to placebo.29 Compared to active control, diuretics significantly improved exercise capacity in CHF patients. (OR 0.37, P=0.007).29 A recent review reappraisaled the role of loop diuretics as first line treatment for CHF concluded that existing evidence of association of loop diuretics with rapid symptomatic relief and decreased mortality supporting the essential role of diuretics in the management of CHF.30 3.3.2 Evidence use of angiotensin II receptor antagonists in the management of CHF The Losartan Heart Failure Survival Study ELITE II, a double-blind, randomised controlled trial involved 3152 patients with NYHA class II-IV heart failure and ejection fraction ?40% reported that there were no significant differences between losartan and enalapril groups in all cause mortality (11.7 vs 10.4% mean mortality rate). However, losartan-treated group showed a lower discontinuation rate due to side effects (9 ·7 vs 14 ·7%, p 0.001), including cough (0.3 vs 2.7%). These results suggested that losartan has similar benefit in improving survival in CHF as enalapril and is significantly better tolerated.31 A randomised trial involved 5010 patients with NYHA class II, III, or IV demonstrated that valsartan significantly reduced the combined end point of mortality and morbidity by 13.2% (P=0.009) and lowered the incidence of hospitalisation (13.8% vs 18.2%, P0.001)) compared to placebo. Significant improvements in signs and symptoms, NYHA class, ejection fraction and qualit y of life were also observed in valsartan-treated group (P0.01).32 3.4 Type II diabetes mellitus 3.4.1 Evidence for continuing sulphoynylureas when initiating insulin therapy in Type II diabetes mellitus A multicenter and randomized controlled trial demonstrated that combination therapy resulted in significantly lower HbA1c levels (p0.001) as compared to insulin monotherapy. There were no significant difference in the hypoglycaemic event rate between the insulin combination and monotherapy (0.36 vs 0.48).33 Kabadi et al. (2003) supported the efficacies of various sulphonylureas in achieving desirable glycaemic control in combination with insulin. Weight gain, number of hypoglycaemic events and daily insulin requirement were significantly lowered (p0.01) for patients treated with both sulphonylureas and insulin as compared to insulin-treated group.34 3.4.2 Evidence against the use of rosiglitazone in diabetic patients with CHF Thiazolinediones are associated with risks of weight gain, fluid retention, peripheral oedema and plasma volume expansion (lead to increased risk of anemia and new or worsening CHF).35-37 A double-blind randomised trial demonstrated that rosiglitazone significantly increased incidence of oedema (25.5% vs 8.8% placebo,P=0.005) and use of CHF medication (32.7% vs 17.5% placebo, P=0.037) in Type II diabetic patients with CHF. 38 Cobitz et al. (2008) evaluated the potential associations of CHF and myocardial ischaemia events in Type II diabetic patients enrolled in clinical trials with rosiglitazones. Higher odds ratio for CHF incidence was obtained when rosiglitazone is combined with insulin or sulphonylurea: rosiglitazone monotherapy versus placebo (OR 0.25), sulfonylurea plus rosiglitazone versus sulfonylurea monotherapy (OR 0.95) insulin plus rosiglitazone versus insulin monotherapy (OR 1.63).39 More myocardial ischemia incidences were reported with rosiglitazone (2.00%) versus con trol (1.53%).39 Nissen et al. (2007) also reported a significant increased risk of myocardiac infarction (OR 1.43, P=0.03) and a borderline significance of increased mortality from cardiovascular causes (OR 1.64, P=0.06) in the rositaglizone group compared to control group.40 The European Medicines Agency (EMEA) and Medicines and Healthcare products Regulatory Agency (MHRA) have issued advice that the use of rosiglitazone in patients with IHD or peripheral arterial disease is not recommended and it is contraindicated in patient with CHF and acute coronary syndrome.4,41 3.4.3 Evidence for combination therapy of statin and ezetimibe or fibrate in treating complication of diabetes mellitus Patients with Type II diabetes mellitus commonly have raised plasma concentrations of low-density lipoprotein cholesterol (LDL-C) or triglycerides, or low plasma concentrations of high-density lipoprotein cholesterol (HDL-C) associated with higher cardiovascular risks. A multicenter, double-blind randomised trial consisting of 1229 Type II diabetic patients demonstrated the efficacy and safety of combination treatment of ezetimibe and simvastatin in providing additional lipid-modifying benefits compared to atorvastatin monotherapy.42 Ezetimibe/simvastatin group showed a significant greater reduction in LDL-C (-53.6% vs -38.3%), superiority in attaining LDL-C levels 70mg/dL (p0.001) and significantly better improvement for total cholesterol, HDL-C and non HDL-C (p?0.001) compared with atovarstatin group. Incidence of clinical adverse effects such as gastrointestinal and hepatocellular-related rashes or allergic reactions and laboratory adverse effects including elevation of creatine kinase and hepatic transaminases were similar in both treatment arms.42 In the simvastatin plus fenofibrate for combined hyperlipidaemia (SAFARI) trial, greater significant changes in triglycerides (-43.0% vs -20.1% with simvastatin alone), LDL-C (-31.2 vs -25.8%) and HDL-C (+18.6% vs +9.7%) were observed in Type II diabetic patients with mixed dyslipidaemia receiving fenofibrate and simvastatin (160/20mg daily) treatment. No drug-related clinical myopathy and liver function severe abnormalities were reported over a 18-week study period.43 The main concern associated with the combination therapy of statin and fibrates is the potential risk of myopathy and rhabdomyolysis, and the interaction is substantial with gemfibrozil.44-45 To date, there is inadequate evidence to conclude that combination treatment of fenofibrate and statin increased the risk of myopathy.46-49 3.4.4 Evidence use of ticlopidine hydrochloride for prevention of macrovascular and microvascular complications of diabetes mellitus A three-year double-blind, randomised-controlled trial involved 435 patients conducted by the Ticlopidine Microangiopathy of Diabetes study (TIMAD) investigators reported that ticlopidine significantly reduced the annual microaneurysm progression by 85% (p=0.03) and showed a preponderance to develop fewer new vessels (p=0.03) in the insulin-treated diabetic patients compared to placebo group. Significant reduction of overall retinopathy progression was also observed in the ticlopidine group (P=0.04).50 Ticlopidine-induced neutropenia (severe in one patient) with no clinical implications, rash or diarrhoea were reported during the treatment period.50 In another study with similar design, Early Treatment Diabetic Retinopathy Study (ETDRS) investigators demonstrated that aspirin had no effect on retinopathy progression in diabetic individuals.51 Due to its association with life-threatening neutropenia or thrombocytopenia, ticlopidine has been limited to patients who are aspirin-intole rant, or who have failed aspirin therapy.52-54 A meta-analysis included 10 trials with 26865 high vascular risk patients investigated the effectiveness of ADP receptor antagonists (ticlopidine and clopidogrel) versus aspirin in preventing serious vascular events in high vascular risk patients. The main outcomes of the trials are ADP receptor antagonists produced a similar significant reduction in the stroke and other serious vascular events compared to aspirin (11.6% vs 12.5%), ADP receptor antagonists significantly reduced gastrointestinal side effects and ticlopidine significantly increased the risk of neutropenia than aspirin.55 The meta-analysis postulated the fact that clopidogrel has a more favourable side effects profile than ticlopidine, therefore it is the thienopyridines of choice.55 4.0 CRITICAL APPRAISAL OF THE EVIDENCE BASED TREATMENTS CONCLUSION The therapeutic management of SARs AEBA is appropriate and SARs response to the treatment is good. Adding nebulised ipratropium bromide to nebulised salbutamol is important to improve the patients pulmonary function and to reduce hospital stay as both agents act rapidly to relieve bronchospasm. Initiation of IV hydrocortisone and short course of oral prednisolone is an essential treatment for AEBA as evidences support that the use of systemic corticosteroids significantly improves lungs performance, reduces relapse rate, hospitalisation and use of short-acting ?2-agonist following the outbreak of acute exacerbation. However, the dose of oral prednisolone should be adjusted to 40-50mg as according to guidelines to achieve the maximal benefits in relieving acute asthma. There are mounting evidences for the benefits of adding LABA to ICS instead of increasing the steroid dose when low dose ICS fail to control asthma symptoms adequately. Combined budesonide/formoterol inhaler has signi ficance in reducing severe exacerbation rates and in improving patient compliance. Patient compliance is of particular concern in this case as SAR with other co-morbid diseases requires polypharmacy. Therefore, Symbicort ® inhaler (combined budesonide/formoterol) should be given to SAR during hospital stay and as discharged medication replacing high dose ICS for the maintenance management of her asthma. The doctors action to start the empirical therapy of cephalosporins (ceftriazxone and cefuroxime) and macrolide (azithromycin) for management of pneumonia in SAR is appropriate as evidenced in clinical trials. These broad spectrum antibiotics have high bacteriological efficacy against the common pathogens implicated in community-acquired pneumonia. SAR was also on appropriate drugs for the management of chronic heart failure. Both furosemide and losartan have significant values in lowering the mortality rate and incidence of hospitalisation, in improving signs and symptoms and q uality of life of heart failure patients. Combination therapy of sulphonylureas and insulin is relatively safe and sufficient to control the blood glucose level of SAR as there are evidences of better glycaemic control and lesser or no differences in hypoglyaemic events as compared to insulin monotherapy. There is a preponderance of the evidences refuting the use of rosiglitazone in the diabetic patients with CHF as rosiglitazone has side effects profile (in particular peripheral oedema and associated cardiovascular risk) unfavorable to CHF patients. Therefore rosiglitazone should be withdrawn from SARs drug regimen. There are no studies concluded the superiority of ezetimibe and statin over fenofibrate and statin and both combinations are proved to have greater effects than monotherapy for secondary prevention of coronary heart disease in diabetic patients. However, the concurrent use of statin and fenofibrate may potentiate myopathy due to pharmacodynamic interaction. Moreov er, SAR had shown to have increased level of creatine kinase. Therefore, ezetimibe and statin should be the preferred combination as both agents do not have clinical interaction and optimal lipid lowering may best be achieved by inhibiting both synthesis and absorption pathways of cholesterol. The use of ticlopidine for the prevention of complications of diabetes mellitus is justified in this case as aspirin is contraindicated in asthmatic patient and ticlopidine has similar effects as aspirin for prevention of coronary and other vascular events. However, ticlopidine is associated with bone marrow toxicity. Therefore, careful haematological monitoring is required for SAR although she has been started on this drug for one year. In conclusion, the therapeutic managements of SARs presenting conditions are considered appropriate although some modifications need to be made to ensure that maximal benefits can be achieved without causing much clinical adverse effects. 5.0 PATIENT MEDICATION PROFILE PATIENT DETAILS Name SAR Consultant Not available General Practitioner Not available Address Not available Gender Female Weight 54kg Height 160cm Community Pharmacist Not available Date of Birth (Age) 54 Known Sensitivities NIL Social History Patient is a housewife. Patients siblings and children are suffering from bronchial asthma. No hx of alcohol drinking and smoking. PATIENT HOSPITAL STAY Presenting complaint in primary care / reason for admission Admission date Day 1 -Patient experienced SOBx3/7(not relieved by taking inhaler), worsening on the admission day. Discharge Date Day 3 -Minimum cough with yellowish sputum, abdominal pain, diarrhoea, fever -No vomiting, no chest pain RELEVANT MEDICAL HISTORY RELEVANT DRUG HISTORY Date Problem Description Date Medication Comments Since childhood Bronchial asthma Before admission T. Rosuvastatin 20mg nocte Dyslipidaemia 3-4 years ago Hypertension Diabetes mellitus Ischaemic heart disease Before admission T. Ticlopidine hydrochloride 250mg OD (Ticlid) Prophylaxis against major ischaemic events Before admission T. Losartan 50mg OD Hypertension Before admission T. Gliclazide 60mg BD (Diamicron ® MR) Diabetes mellitus Before admission T. Fenofibrate 160mg OD Dyslipidaemia Before admission T. Ezetimibe 10mg OD (Ezetrol) Dyslipidaemia Before admission T. Rosiglitazone 4mg OD (Avandia) Diabetes mellitus Before admission T. Famotidine 20mg OD Prevent GI ulceration Since childhood MDI Salbutamol 200 µg 1puff prn Asthma Since childhood MDI budesonide 200 µg 2puffs bd Asthma Clinical/ Laboratory tests Date Results Plasma potassium (3.5-5.1mmol/L) Day 1 Day 2 5.1 5.0 Urea (1.7-8.5mmol/L) Day 1 Day 2 16.3 24 Creatinine (60-130 µmol/L) Day 1 Day 2 270 298 CrCL calculated (78-120ml/min) Day 1 17ml/min(severe renal impairment) Glucose random (11.1mmol/L) Day 1 18.8 Alb (35-50g/L) Day 1 34 Globulin (25-39g/L) Day 1 45 A/G ratio (0.9-1.8) Day 1 0.8 Hb (13.5-18g/dl) Day 1 Day 2 9.4 10.0 RBC (4-5.2)x1012/L Day 1 Day 2 3.4 3.6 Plat (150-400)x109/L Day 1 Day 2 410 400 WCC (4-11) x109/L Day 1 Day 2 17.1 10.8 Neutro (40-74)% Day 1 Day 2 96 86 Lymphocytes (19-48)% Day 1 Day 2 3 8 Monocytes (3.4-9)% Day 1 Day 2 1 6 CK (26-140)IU/L Day 1 156 LDH (240-480)IU/L Day 1 627 SpO2 Day 1 98%, pCO2 (4.8-5.8) kPa Day 1 4.3 pO2 (11.3-13.3) kPa Day 1 9.9 Pulse rate Day 1 111bpm Lung sound Day 1 Rhonchous PEFR Day 2 Day 3 200-220ml/min 250ml/min Chest x-ray Day 1 Shadowing in right lower zone Blood glucose readings (mmol/L) Time Date 0800 1200 1720 1100 Day 1 24.9 14.2 7.3 14.7 Day 2 15.8 12.4 19.7 16.2 Day 3 12.6 4.2 CLINCIAL MANAGEMENT Diagnosis Pharmaceutical Need Acute exacerbation bronchial asthma Neb salbutamol 5mg+ neb ipratropium bromide 500 µg+normal saline 4hourly, IV hydrocortisone 100mg stat,oral prednisolone 30mg od, MDI budesonide 200 µg 2puffs bd, Underlying pneumonia Antibiotics Chronic cardiac failure IV furosemide 40mg bd, Strict I/O chart(restrict fluid intake 800cc/day), low salt intake, KIV to start S/C Clexane if trop-T +ve Uncontrolled diabetes mellitus Insulin, Oral hypoglycaemics Ward medication Drug route Dose frequency Start date Stop date Indication/ Comments T. Gliclazide (Diamicron ® MR) 60mg bd Day 1 Diabetes mellitus T.Rosiglitazone 4mg od Day 1 Diabetes mellitus T.Rosuvastatin 20mg nocte Day 1 Dyslipidaemia T.Fenofibrate 160mg od Day 1 Dyslipidaemia T.Ezetimibe 10mg od Day 1 Dyslipidaemia T.Lovastatin 20mg nocte Day 1 Dyslipidaemia T.Ticlopidine HCL 250mg od Day 1 Prophylaxis against ischaemic T.Losartan 50mg od Day 1 CHF T.Famotidine 20mg od Day 1 Prevent GI ulceration Neb ipratropium bromide 500 µg, salbutamol 5mg normal saline 2:1:2 qqh Day 1 Day 3 AEBA IV Hydrocortisone 100mg stat Day 1 Day 1 AEBA Neb Salbutamol 200 µg prn 1 puff prn Day 1 AEBA/chronic asthma MDI budesonide 200 µg 2 puffd bd Day 1 AEBA/chronic asthma T. Azitromycin 500mg od Day 1 Day 3 Pneumonia IV Ceftriaxone 2g stat Day 1 Day 2 Pneumonia IV Furosemide 40mg bd Day 1 Day 2 CHF S/C Atrapid 5? , 10? Day 1 Day 2 Diabetes mellitus T. Prednisolone 30mg od Day 2 AEBA MDI beclomethasone 200 µg 2puffs tds Day 2 Chronic asthma T.Cefuroxime 250mg bd Day 2 Pneumonia T. Furosemide 40mg od Day 2 CHF S/C Mixtard 30/10? Day 3 Diabetes mellitus Discharged medication Drug route Dose frequency Indication/ Comments T. Gliclazide (Diamicron ® MR) 60mg bd Diabetes mellitus T.Rosiglitazone 4mg od Diabetes mellitus T.Rosuvastatin 20mg nocte Dyslipidaemia T.Fenofibrate 160mg od Dyslipidaemia T.Ezetimibe 10mg od Dyslipidaemia T.Lovastatin 20mg nocte Dyslipidaemia T.Ticlopidine HCL 250mg od Prophylaxis against ischaemic T.Losartan 50mg od CHF T.Famotidine 20mg od (6/52) Prevent GI ulceration Neb Salbutamol 200 µg 1 puff prn Chronic asthma MDI budesonide 200 µg 2 puffs bd Chronic asthma T. Prednisolone 30mg od (5/7) AEBA MDI Beclomethasone 200 µg 2 puffs tds Chronic asthma T.Cefuroxime 250mg bd (5/7) Pneumonia T. Furosemide 40mg od CHF S/C Mixtard 30/10? Diabetes mellitus PHARMACEUTICAL CARE PLAN Date Care Issues/ Desired outputs Actions Outputs Day 1 Confirm past medication history Ensure appropriate pre-admission medication continued and prescribed correctly. -Co-administration of rosuvastatin (pre-admission drug) and lovastatin (newly prescribed) together with other lipid-lowering agents are inappropriate. Confirm with patient that medicines given are correct. Ask patients family member to bring her old medication at home in order to confirm her medical history. Rosuvastatin should not be continued. (avoid in patients with CrCl ?30ml/min). Dose of fenofibrate should be reduced to 67mg od in patient with CrCl?20ml/min. (BNF) -Patients family members brought her medication at home and past medical history was confirmed. -Rosuvastatin and high dose fenofibrate were still given to patient. Day 1 Appropriate management of AEBA Any one of: -PEF 33-50% best or predicted -RR? 25/min -HR?110/min -inability to complete sentences in one breath -According to NICE/GINA guidelines, drugs for AEBA management include -Oxygen, nebulised beta2 agnonist, nebulised ipratropium bromide, IV hydrocortisone, oral prenisolone, inhaled corticosteroids Drugs indicated for AEBA were given. Oral prednisolone should be adjusted to dose of 40-50mg od for at least 5 days (BTS/GINA) Ensure close monitoring of PEFRs before and after bronchodilator treatment. Advise patient to avoid trigger factor (dust) Suggest self- monitoring of PEFR at home (PEF record keeping) -Dose of oral prednisolone was still not adjusted. -PEFR improved. Day 2 Management of chronic asthma -High dose steroids (MDI budesonide 200 µg 2puffs bd+ MDI beclomethasone 200 µg 2 puffs tds) -Local S/E: Oral candidiasis -Systemic S.E: Adrenal suppression, Cushings syndrome, precipitation of diabetes, oesteoporosis LABA should be added to ICS instead of increasing the dose of steroids. (BTS/GINA) Symbicort ® should be prescribed. Not done Day 1-Day 3 Poor compliance with monitoring and treatment (poor inhaler technique) To prevent subsequent attack: -Check inhaler technique -Education on the correct use of the newly-prescribed inhaler device. -Any observed deficiencies should be corrected before discharged. -Effective counselling of asthma management Simple written instructions reminders of when to use medication were given. The pharmacist checked SARs inhaler technique and SAR was educated to use MDI and nebuliser correctly during hospital stay. The pharmacist counselled SAR on the importance of adherence to drug regimen. Advised SAR to avoid trigger factor (dust) Should also be suggested to self- monitored PEFR at home (PEF record keeping) Counselled. Day 1 Appropriate management of pneumonia -IV Ceftriaxone 2g stat -Oral azithromycin 500mg od (3/7) -Oral cefuroxime 250mg bd (5/7) Monitored signs of recovery and WBC count. Repat CXR and look for progression/complications Replaced IV to tablet form when patient showed recovery of pneumonia. (BTS) Ensure completion of antibiotic course. Vaccinations against pneumococcal infection and influenza should be recommended. (BTS) -Patient showed signs of recovery. -On day 2, oral cefuroxime was given replacing IV ceftriaxone. -Patient was told to complete the course of antibiotic at home upon discharged. -Not done. Day 1 Appropriate management of CHF Furosemide was given to alleviate pulmonary oedema and ankle swelling. Restricted intake of fluid (800cc/day) Furosemide should be given orally with reduced frequency and total daily dose when the patient showed recovery of ankle swelling. Monitored plasma K+ level, renal function bp. Losartan 50mg od was continued. -Lungs were clear, no crepitation. -Swelling of ankle resolved. -Input/output restricted. -On day 2, IV furosemide 40mg bd was replaced by oral furosemide 40mg od. Plasma K+ decreased a bit on day 2 (5.0mmol/L), bp was under controlled. Day 2 Avoidance of hypokalaemia -High dose steroids + salbutamol+ furosemide increase the risk of hypokalaemia. Potassium chloride 600mg bd (appropriate dose for severe renal impairment pt) Close monitoring of plasma K+ level. -Not given. Day 1 Appropriate management of uncontrolled DM -Addition of insulin to the two oral hypoglycaemic agents after the dual oral therapy fails (Targets for blood glucose 4-7mmol/L pre-meal, 9mmol/L post-meal, target HbA1c ?6.5%, practically 7%) Mixture of short intermediate acting insulin was given. Close monitoring of blood glucose and HbA1c levels. Monitored signs of hypoglycaemia. Educated on proper insulin injection techniques -Blood glucose level was under control. No signs of hypoglycaemia. -Measurement of HbA1c was not taken. -Patient and her family members successfully demonstrated the use of insulin injection. Day 1 Safe use of rosiglitazone evidences refuting the use of rosiglitazone in the diabetic patients with CHF as rosiglitazone is associated with oedema, plasma volume expansion and increased cardiovascular risks. -Not recommended in patients with IHD or peripheral arterial disease, contraindicated with CHF and ACS. (EMEA,BTS) Rosiglitazone should be withdrawn. -Rosiglitazone was still given to patient. Day 1 Anaemia Hb (13.5-18)g/dL-9.4 RBC (4-5.2)X1012/L -3.4 -Anaemia is common in patients with moderate to severe HF. -Most likely exacerbated by administration of rosiglitazone. Withdraw rosiglitazone Monitor Hb and RBC If the anaemia problem is not improved, erythropoeitin and iron therapy can be considered. Not done. Day 1 Primary and secondary prevention of cardiovascular events and complications of DM Polypharmacy in the use of lipid-lowering agents. -Rosuvastain, lovastatin, ezetimibe,fenofibrate Rosuvastatin lovastatin act via the same mechanism of action. Dual therapy of statin and fenofibrate potentiate the risk of myopathy (pharmacodynamic interactions) Avoid rosuvastatin if CrCl?30ml/min Reduce dose of fenofibrate to 67mg od if CrCl?20ml/min Rosuvastatin and fenofibrate should not be given. (CrCl: 17m/min) Lipid profile should be done. LFTs should be carried out to avoid the risk of hepatotoxicity. Should advise patient to report promptly unexplained muscle pain, tenderness or weakness. -Four lipid lowering agents were still continued in the patient. -Lipid profile was not done. -No abnormalities of liver function. Day 1 Safe use of ticlopidine hydrochloride. -Similar efficacy as aspirin in reducing cononary and other vascular risk -Limited to patients who are aspirin-intolerant/ who have failed aspirin therapy. -Associated with bone marrow liver toxicity. Close monitoring of haematological LFTs should be done. Should be told how to recognise signs of blood disorder or jaundice. If adverse effects occur, clopidogrel can be considered (more favourable side effect profile). No signs of neutropenia, thrombocytopenia and liver abnormalities. Day 3 Patient for discharge Ensure appropriate medication prescribed and the patient is counselled appropriately prior discharged. Check discharged prescriptions against ward medication chart. Review the appropriateness of discharged medication. Ensure all information relevant to primary care included. Reinforced the importance of patient compliance and follow-up reviews. Counselled patient on the indications and possible side effects of those prescribed medications. Advised patient on healthy lifestyles: Regular exercise Adherence to balance diet which is high in oily fish, fruit, vegetables and fibre; low in calories, sugar, salt saturated fat. -Review of appropriateness of discharged medication was not done by the pharmacist. -Follow-up appointment was made and the patient was told. -Patient was given diabetic diet counselling prior discharged. Day 3 Self management education and personalised asthma action plans -Being able to monitor symptoms, PEF measurements, drug usage and knowing how to deal with fluctuations in severity of asthma according to written guidance. Should be offered self-management education that focuses on individual needs. (mentioned earlier) Should be given written personalised action plans. -No personalised asthma action plans was given.

Critical Book Review No Shame in My Game - 1612 Words

When someone thinks of the poor they instantly imagine a homeless man sleeping in a cardboard box or the nearest garbage can, but the working poor especially in the inner-city is commonly overlooked by society. However the working poor, in this case the working poor in the inner-city, are people advancing to try and make their lives better. They are taking minimum wage jobs so that they can barely afford a roof over their heads. Within Katherine Newman s novel No Shame In My Game, she studies the working poor in the inner-city to draw conclusions about how to help them and dispute common stereotypes and the images people commonly view. Newman s conclusions along with the way she had conducted her case study will be evaluated for her†¦show more content†¦To relocate the volumes of people to achieve her goal of social change would not be received well by the middle class. The middle class takes property very seriously, if someone was to relocate them from their nice suburban h ouses and environment straight into Harlem one would be extremely angry. The rest of her proposals are ideas that would seem to work to help improve the working poor and influence their job situation but only for small groups. Newman s remedies are in a small scale that is geared to help small groups, which is largely unequal to the scale of need for all the working poor. Several of her proposals involved methods that we use today such as a reform of unionization for low wage workers and a reform to improve the health care and child care for the poor. One of her best proposals by far is to incorporate a school to work program. This is largely similar to the cooperative education experience many receive at Kettering University. This has many advantages including the school, the school s teachers, and the employers. The schools would benefit from a sense of purpose that is now incorporated within the student body and gives the school an opportunity for a system of punishments and rewa rds available. Employers of the students greatly benefit as well. The Teachers and employers would form strong relationships in which teachers provide reliable information about quality students in return for the employers offerShow MoreRelated Critical Book Review of No Shame in My Game by Katherine Newman1591 Words   |  7 PagesCritical Book Review of No Shame in My Game by Katherine Newman When someone thinks of the poor they instantly imagine a homeless man sleeping in a cardboard box or the nearest garbage can, but the working poor especially in the inner-city is commonly overlooked by society. However the working poor, in this case the working poor in the inner-city, are people advancing to try and make their lives better. 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The Door in the Face Technique - 1077 Words

Principle of Persuasion: The door-in-the-face (DITF) technique is a simple, yet effective two-step technique to gaining behavioral compliance from a recipient. This technique works by first making a costly, large initial request that the recipient of the message will most likely decline, and then following up the initial request with a smaller, less costly, and more realistic one (Rodafinos, Vucevic, Sideridis, 2005). Meanwhile, compliance with the smaller, less costly request is what the user has been aspiring to attain all along. The DITF technique is persuasive and effective in attaining the desired request due to several reasons: First, people are a lot more likely to comply with the second request when it is contrasted against the initial large request. This makes the second request seem a lot smaller than it may actually be and therefore, a lot more reasonable to comply with. Second, DITF is effective due to the norm of reciprocity, which states that people generally feel comp elled to return a favor; if one person gives something up, so too should the other. In the door-in-the-face technique, when we give up the larger initial request and figuratively settle for the smaller request, the receiver feels obligated to return the favor and satisfy our request. Furthermore, DITF is effective because in refusing the more costly initial request, the user may experience guilt and emotionally persuade themselves to oblige with the second request to avoid this negativeShow MoreRelatedAn Experimental Study of the Door in the Face Technique2271 Words   |  10 PagesSocial Psychology Experiment Replication (Group Project) An experimental Study of The Door in the Face Technique Date: 28/4/2009 ABSTRACT Door in the face technique is a persuasion method in which a requester first asked an extreme request (which was refused) and then a smaller request. 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The Pros And Cons Of Foreign Conflicts - 1233 Words

Financial backers play a role in enabling the shameless, but for those conducting abusive military campaigns in Syria, South Sudan, or Yemen, arms suppliers remain among their most important enablers. Although not impossible, it is much more difficult to continue to commit abuses on a large scale without the influx of new weapons and ammunition, either from abroad or through domestic production. Many human rights groups’ mandates do not extend to stopping wars, which conflicts with a policy of neutrality in all armed conflicts. Instead, advocates push for hostilities, when they occur, to be conducted according to international humanitarian law. Nonetheless, in places like Syria, rights advocates have argued the UN Security Council to†¦show more content†¦In June 2016, the UN peacekeeping mission in the Central African Republic decided to stop accepting Burundian police due to concerns about â€Å"serious and ongoing† human rights violations by police back in Burundi. The Burundian government, like many developing countries, benefits from the salaries paid to their troops and participating in UN missions. In November 2016, the US State Department suspended a planned sale of 26,000 assault rifles to Duterte’s Philippines following an objection raised by US Senator Ben Cardin about Duterte’s abusive â€Å"war on drugs.† Since 2012, human rights groups have pointed to the role of Russia’s state-owned arms dealer, Rosoboronexport, in selling the Syrian government weapons and urged responsible governments and corporate actors to avoid all new business dealings with the company. Campaigners have also asked arms fairs in Paris and London to stop featuring Rosoboronexport as an exhibitor. Human rights groups have also directly challenged UK-based BAE Systems and the US-based Boeing and General Dynamics for their role in supplying Saudi Arabia with weapons that enable abuses in Yemen. 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