Idiom Comparison Essay Example for Free

Idiom Comparison Essay As a foreign student learning English, comparison idioms are really a big problem for me as well as other learners. There are over 3000 idioms in the dictionary, so understanding and memorizing all of them are a hard issue. Some students, even though, live in America or England for such a long time, they are still unable to understand what the native people are saying. In a circle of students, native English speakers speak to other native speakers differently from the foreign students. And the foreign students here is unable to follow what they are saying to each other. More than that, comparison idioms are one of major aspects that can easily discourage a person in conversation with each other if he/she does not know what to imply. If somebody ask me: Is it necessary to study an idiom like â€Å"rain like cats and dogs†? , I will asnwer Yes because idioms are part of daily speech. It makes our utterances smoothly and transmit the information to listeners in a smart way. As a matter of fact, in this essay, we will firstly find a clear view of the definition of idioms and some structures to recognize a comparison idiom, then will be a part related to contrastive analysis; that is similarities and differences between english and Vietnamese comparison idioms; lastly, some problems and solutions of studying idioms may be important to learners. Definition of idioms Definition Idioms have become very popular with the linguistic learners; however; not everyone can find the complete definition for this term. Each professor has his or her own assumption and we, the learners, have to consider much when we want to apply those idioms into study. For example, the Longman Dictionary of Language Teaching and Applied Linguistics, idioms were defined as: â€Å"an expression which function as a single unit and whose meaning cannot be worked out from its separate parts. †. Moreover, with the Oxford Advanced Learner’s Dictionary, the writer defines idioms differently: â€Å"a phrase or sentence whose meaning is not clear from the meaning of its individual words and which must be learnt as a whole unit. As we have seen, definition of idioms is quite different between the Longman Dictionary and Oxford one and maybe different from other books as well, but on reflection, they do not have much conflict, all of those share the basic idea: â€Å"they are words, phrases or expressions that cannot be taken literally; when used in everyday language, they have a meaning other than the basic one you would find in the dictionary. †. Learning them make understanding and using a language a lot easier and more fun. Structure used for comparing Although we have worked out some definitions of idioms above, most of learners are still confused with the question: â€Å"How can we identify an idiom of comparison? †. Consequently, identification should be taken into consideration so as to have an insight into different types of idioms of comparison. There are various ways of identifying based on different criteria because the exploration is quite hard and unfeasible. Here are just two main ways that have been considered most: * Identification based on component words or phrases Identification based on grammatical structure By word and phrase With this aspect, idioms of comparison can be divided into three groups: * Comparison with adjectives This kind of comparison can be constructed as the following structure: As + adjective + as + (a/an/the) Noun It is used to describe the similarities between people, things or places. However, in this structure, the similarities are exposed in a clear way, explicitly rather than other s tructure. The meaning as well as the characteristics of the adjectives are conveyed symbolically through some related things in our lives so that people can easily think of when they come across those adjectives. For example: as sharp as razor, as innocent as love, as unchangeable as the past, as jolly as a sandboy. In Vietnamese idioms, typical examples of comparison are: nhat nhu th? d? , den nhu than, d? p nhu tien†¦

Comparison of Beta Blockers Use

Comparison of Beta Blockers Use 1.1 Background Beta-blockers are a medication used to treat high blood pressure and heart problems. They are used by millions of people around the world everyday. In 2004, they were the fifth most widely prescribed class of medicine. Beta-blockers are effective, life-saving medicines with more than 25 years of widespread and generally safe use. There are fourteen beta-blockers are currently available. These included Acebutolol, Atenolol, Betaxolol, Bisoprolol, Carvedilol, Esmolol, Labetalol, Metoprolol, Nadolol, Penbutolol, Pindolol, Propranolol, and Timolol. Beta-blockers are just one class of prescription medicine used to treat high blood pressure and heart disease. Four other classes are commonly used to treat high blood pressure, for example. These include the diuretics, calcium channel blockers, ACE inhibitors, and angiotensin-receptor blockers. These four plus beta blockers are often used in combination, two or more at a time. Indeed, many people with high blood pressure will require two or more high blood pressure medicines to bring their blood pressure down to a normal and healthy range. Although they are used primarily to treat people with high blood pressure, they are also used to treat other heart conditions. These include angina (heart or chest pain), abnormal heart rhythms, coronary artery blockages, and heart failure. They are also used, along with other treatments, to help prevent repeat heart attacks in people who have already had one, to prevent migraine headaches, and to treat performance or stage-fright anxiety. High blood pressure is one of the most significantly and persistently under-diagnosed and under-treated medical conditions. It raises your risk of heart disease, heart attack, heart failure, stroke, dementia, vision loss, and kidney failure. In most who have high blood pressure, it is a lifelong condition. Yet studies show that only 30% of people with high blood pressure getting the medicines, care, and blood pressure control they need. Uncontrolled high blood pressure is a leading cause of death. Because it has no symptoms and often goes undetected, high blood pressure is often called the nations leading silent killer. Beta-blockers work by blocking adrenaline in the heart and blood vessels. Adrenaline speeds up the heart rate, makes the heart muscle contract more strongly, and constricts arteries throughout the body. All these raise blood pressure. In blocking adrenaline, beta-blockers slow down the heart and reduce its workload. That helps to decrease blood pressure. Choosing a beta-blocker, and its dose, depends on what people need it for. Studies show that some beta blockers are more effective and safer than others for certain conditions. People respond to the various beta-blockers differently. There are important differences in how the various beta-blockers work that will affect the use of them. In effect, beta blockers differ in the type of beta receptors they block (ÃŽÂ ²1, ÃŽÂ ²2, and ÃŽÂ ±) and, therefore, their effects. Non-selective beta blockers, for example, propranolol, block ÃŽÂ ²1 and ÃŽÂ ²2 receptors and, therefore, affect the heart, blood vessels, and air passages. Selective beta blockers, for example, metoprolol primarily block ÃŽÂ ²1 receptors and, therefore, mostly affect the heart and do not affect air passages. Labetalol and carvedilol block beta and alpha-1 receptors. Blocking alpha receptors adds to the blood vessel dilating effect of labetalol and carvedilol. Beta-blockers are generally safe medicines. They have not been shown to cause any serious long-term or irreversible negative consequences, even after many years of use. But side effects are common among people taking beta-blockers. The majority of people can expect to experience at least one. These include fatigue or drowsiness, dizziness or lightheadedness, slow heartbeat, low blood pressure, difficulty breathing, numbness, tinkling or coldness of fingers, toes or skin, weight gain, mental depression, disturbing dreams, reduced libido, erectile dysfunction in men, or ability to reach orgasm in both men and women. Most side effects can be avoided or minimized by starting with a low dose and increasing it gradually. Also, some of these adverse effects go away or diminish in time, after body gets used to the drug. Overall, the strongest evidence on beta-blockers links them to a lower risk of repeat heart attack and early death in the aftermath of a heart attack. More than 60 studies have examined this, and all have found a marked benefit for the pills. There is also compelling evidence that some beta blockers lower the risk of death in people with heart failure, preventing 3.8 deaths per 100 patients in the first year of treatment. Therefore, everyone who has had a heart attack should be taking a beta-blocker. Below are the list of beta-blockers that use in Klinik Kesihatan Greentown: No:  1. Generic Name:  Atenolol Trade Name:  TENORMIN ® Dosage Form:  Tablet Strength:  100mg No:  2. Generic Name:  Bisoprolol Trade Name:  CONCOR ® Dosage Form:  Tablet Strength:  2.5mg , 5mg No:  3. Generic Name:  Carvedilol Trade Name:  DILATREND ®, CASLOT ® Dosage Form:  Tablet Strength:  6.25mg , 25mg No:  4. Generic Name:  Labetalol Trade Name:  TRANDATE ® Dosage Form:  Tablet Strength:  100mg No:  5. Generic Name:  Metoprolol Trade Name:  BETALOC ® Dosage Form:  Tablet Strength:  100mg No:  6. Generic Name:  Propranolol Trade Name:  INDERAL ® Dosage Form:  Tablet Strength:  40mg 1.2 Objectives 1.2.1 To list down types of beta-blockers in Klinik Kesihatan Greentown. 1.2.2 To analyze the usage of each beta-blockers in Kinik Kesihatan Greentown. 1.2.3 To compare the most commonly used beta-blockers in Klinik Kesihatan  Greentown based on the results. CHAPTER 2:  LITERATURE REVIEW From the past, beta blockers is widely use for the treatment of hypertension besides treatment such as stable and unstable angina, arrhythmias, bleeding esophageal varices, coronary artery disease, asymptomatic and symptomatic heart failure, hypertension migraine, and secondary prevention post-myocardial infarction (Mark Helfand, MD, et al., 2007). Although some study shows that beta-blockers are not first-line drugs in the treatment of hypertension (Wiysonge CS, et al., 2007) but when initiating a beta-blocker, it is proven to be as effective and safe as initiating an ACE-inhibitor first (Ferenc Follath, 2006). Besides, beta blockers provide similar clinical outcomes and are associated with fewer adverse events than calcium antagonists in randomized trials of patients who have stable angina. (Paul A. Heidenreich, MD, et.al., 1999) There is also evidence that suggest B-blockers are useful in managing angina and reducing mortality after myocardial infarction and in heart failure (H T Ong, consultant cardiologist, 2007) but beta blockers appear to be less effective when used as monotherapy in black hypertensives (Walter Flamenbaum, MD, 1985). Additionally, beta-blockers may be considered as a first-line option in women of child-bearing potential because of concern about foetal renal maldevelopment with ACE inhibitors or angiotensin receptor blockers (British Hypertension Society, 2008). When starting beta blockers, it should be started at the lowest dose, with the dose increased every two to four weeks until the target dose or highest tolerated dose is reached because beta-blockers showed little evidence of useful antiarrhythmic action in the dosage used (J M Roland, et.al., 1979). It also should reconsider in the treatment of hypertension since doses smaller than those recommended are almost as effective and much cheaper. (A K Scott, et al., 1982) On the other side, when beta blocker treatment given as secondary prophylaxis after myocardial infarction it is highly cost effective (G Olsson, L A Levin, N Rehnqvist, 1987). Among all the beta-blockers, atenolol had the most widely used in Klinik Kesihatan Greentown because study proven atenolol is more effective than placebo in lowering blood pressure but does not appear to reduce the rates of cardiovascular morbidity or mortality (Carlberg B., et al., 2004). One of the studies also shown that the use of atenolol (started 72 h before operation) is effective in reducing the incidence of supraventricular arrhythmias following elective coronary artery bypass operations in patients with good left ventricular function (R. K. Lamb, et al., 1988). When compare between atenolol versus nifedipine versus the combination, atenolol was slightly better than nifedipine on exercise time, but the combination was slightly better for decreasing the number of attacks (El-Tamimi, H. Davies, G.J., 1992). Anyway, atenolol should be avoided in the early stages of pregnancy and given with caution at the later stages, as it is associated with fetal growth retardation, which is related to duration of treatment. (Lydakis C., et al., 1999) Metoprolol, which shows the second higher usage in Klinik Kesihatan Greentown, is an effective drug for treatment of stable exercise-induced angina pectoris (Arnman K Rydà ©n L. 1993) where metoprolol also can reduce total mortality, sudden death, and death due to progressive heart failure and improved quality of life (Mark Helfand, MD, et al., 2007). There is also a study about 62 patients taking metoprolol 100 mg twice daily, nifedipine 10 mg three times daily and the combination in a randomised double blind crossover study, metoprolol was better than nifedipine; the combination was better again (Uusitalo, A, et.al, 1986). On the other side, both carvedilol and metoprolol also showed parallel beneficial effects on symptoms, exercise, ejection fraction, and oxidative stress in heart failure (Marrick L. Kukin, MD, et. al, 1999). Treatment with metoprolol will resulted in lower all-cause mortality than treatment with a thiazide diuretic (Mark Helfand, MD, et al., 2007) but metoprolol did not benefit mortality or ischemic events in a longer-term (Mark Helfand, MD, et al., 2007). Although carvedilol and immediate release metoprolol had similar effects on quality of life, but metoprolol improved exercise capacity more (Mark Helfand, MD, et al., 2007). Yet, the chronic use of the more selective beta-1 selective blockers such as atenolol and metaprotenol has been shown in several studies to not significantly increase asthma or worsen pulmonary function (J Respir, 2003). Among all the beta blockers, labetalol is among the physicians choice because the efficient hypotensive action, together with apparent freedom from maternal and fetal side-effects, and consequent improved perinatal mortality, suggest that it is a suitable drug for use in pregnancy complicated by hypertension (C A Michael, 1979). Besides, labetalol appears to be better able to prevent the appearance of fetal growth retardation compare to atenolol (Lardoux H, et al., 1983). The most significant effect is when comparing side-effect liabilities, it is clear that quantitatively labetalol produces no greater burden of side-effects than drugs of the ÃŽÂ ²-adrenoceptor-blocking group (B. N. C. Prichard D. A. Richards 1982). It also may be considered relatively safer then pure non-selective beta-adrenoceptor blocking drugs in patients with airways obstruction (S H Jackson D G Beevers 1983). Among the incidence of side-effects, was similar with atenolol, metoprolol and pindolol but was slightly less with labetalol (J J McNeil W J Louis 1979). Of all this reason, labetalol become one f the common prescribe drug for pregnant women. For the next drug, propranolol, it should be used with care in patients with known vascular disease (P D McSorley D J Warren 1978). Carvedilol which is other beta blockers has a powerful antiarrhythmic effect, where a study shows after AMI, even in patients already treated with an ACE inhibitor, carvedilol suppresses atrial as well as ventricular arrhythmias in these patients (McMurray, J., et al., 2005). It also may adversely affect recovery from severe hemorrhagic shock (Taniguchi T., et al., 2009). Next, carvedilol is the only beta blocker shown to reduce mortality in post-MI patients who are already taking an ACE inhibitor (Mark Helfand, MD, et al., 2007). In one of the study also shown that administering carvedilol in addition to conventional therapy reduces mortality and attenuates myocardial remodelling in patients with left ventricular dysfunction following acute MI. Mortality was significantly lower with carvedilol than with metoprolol in patients with mild to severe CHF, suggesting that carvedilol may be the preferred beta-blocker (Keating GM Jarvis B. 2003). However, patients with CHF and asthma tolerated carvedilol poorly and because of that asthma still remain a contraindication to beta-blockade (Kotlyar E, et al., 2002). For bisoprolol, neither dose of bisoprolol showed any obvious influence on reducing attack duration or severity (Mark Helfand, MD, et al., 2007). CHAPTER 3:  METHODOLOGY 3.1 Study Design A case control study is conducted from 1st Mac 2009 till 8th May 2009. We will identify the usage of Beta Blocker drugs in Klinik Kesihatan Greentown. Inclusion criteria for this study are based on the date noted on the cupon. Exclusion criteria is the date for the part supply prescriptions which we will take the last date the patient comes to collect the their medication. A total of 3 months prescription (October 2008 till December 2008) will be taken to be analyzed. Comparison between all beta blockers is then done when all data has been analyzed. 3.2 Data Collection Each month of prescription is divided among us group members to evaluate and count the frequency usage of those Beta Blocker drugs. Time that given to finished the evaluation of the prescription is 1 month from the date the prescription is given. The Beta Blocker drugs that has be taken count for this study is between Metoprolol Tartrate, Atenolol, Carvedilol, Propanolol HCL, Bisoprolol Fumarate, and Labetolol HCL. 3.3 Statistical Methods/Data Analysis Data has been analysis using Microsoft Excel which the results is shown through bar and pai chart. 3.4 Ethical Consideration Permission to conduct this study is obtained from the chief pharmacist and our local preceptor of Hospital Raja Permaisuri Bainun and Klinik Kesihatan Greentown. CHAPTER 4:  RESULTS Graph 1 show the total usage of each type of Beta-blockers used in October 2008 at Klinik Kesihatan Greentown. From the graph, we found that atenolol is among the most frequently used Beta-blocker drug used by Klinik Kesihatan Greentown on October 2008 which is 449 patients, followed by metoprolol, 404 patients, propranolol, 20 patients, labetalol and carvedilol, 1 patient each, while no patient was prescribed with Bisoprolol. Graph 2 shows the total usage of each type of beta-blockers in November 2008 at Klinik Kesihatan Greentown. The graph indicates that atenolol is the most highly used if compared with other Beta-blockers which have 358 patients, followed by metoprolol, 324 patients, propranolol, 35 patients, bisoprolol, 4 patients, labetalol, 2 patients and carvedilol, have 1 patient only. Graph 3 shows the total usage of each type of Beta-blockers in December 2008. From the graph we can conclude that atenolol rated as the most widely used where there are 377 patients, followed by metoprolol, 303 patients, then propranolol, 27 patients, bisoprolol, 14 patients, labetalol, 3 patients and carvedilol, 8 patients. Graph 4 shows the overall usage of each beta-blocker used in Klinik Kesihatan Greentown based on total amount of prescriptions prescribed on October, November and December 2008. From types of beta-blocker, we can conclude that atenolol is the most widely used which have 1184 patients compared with other beta-blocker drugs. While metoprolol is the second beta-blocker drug that commonly used which have 1034 patients, followed by propranolol, 82 patients, bisoprolol, 18 patients, carvedilol, 10 patients and labetalol, 6 patients. Graph 5 displays the total usage of beta-blockers based from October, November and December in year 2008 at Klinik Kesihatan Greentown. From the overall, the month of October 2008 shows the highest percentage of beta-blockers used in Klinik Kesihatan Greentown which are 38% or total usage are 875, followed by December 2008 which are 31% or total usage are 732 and November 2008 are 31% or total usage are 724. CHAPTER 5:  DISCUSSION 5.1 Atenolol Beta-blockers work by blocking adrenaline in the heart and blood vessels. Adrenaline speeds up the heart rate, makes the heart muscle contract more strongly, and constricts arteries throughout the body. All these raise blood pressure. In blocking adrenaline, beta-blockers slow down the heart and reduce its workload. That helps to decrease blood pressure (Houghton T, Fremantle N, Cleland JG. 2002). Atenolol in this case is a beta blocker used not only to treat hypertension but also is the primary medication treatment for angina and after an heart attack (American Academy of Family Physician, 2000). Based on our study, at Klinik Kesihatan Greentown the most used beta blocker from October 2008 till December 2008 was atenolol. This could be due to many factors; one of it to be the effective treatment towards treating hypertension. It is also widely use because doctors nationwide has been prescribing this drug for a long time and it is shown by patient age on the prescription studied, geriatric patients prefer sticking to atenolol than changing to other beta blockers as they safe and satisfied with the treatment of atenolol. Atenolol also has very less adverse effects compared to other beta blockers .It is also known to effectively lower blood pressure to its normal range by decreasing the heart rate. It easy to consume as the daily dosing is usually 1 tablet a day(100mg) or half a tablet a day(50mg) ( Shekelle, P. G., et al., 2003 ). According to a study it has chosen four of the five indicated beta blockers as Best Buy drugs for people with angina, based on price. They are atenolol, metoprolol tartrate, and propranolol. Generic acebutolol is substantially more expensive than these four and no more effective. Taking a beta-blocker after a heart attack lowers the risk of a repeat attack and death by 15% to 25%. Five beta-blockers -atenolol, carvedilol , metoprolol tartrate, propranolol, and timolol- have been proven in studies to reduce deaths in people whove had heart attacks. The evidence is somewhat stronger for atenolol, however. On that basis, and because they are available at lower cost than carvedilol (Coreg) and timolol, atenolol is chosen as one of the best buys around. Studies of carvedilol are complicated by its use therefore atenolol is a much suitable drug to be considered alongside its market price (Houghton T, Fremantle N, Cleland JG. 2002). 5.2 Metoprolol Metoprolol is the second commonly used in Klinik Kesihatan Greentown after atenolol. It is a first-line therapy for hypertension, angina, congestive heart failure, coronary artery disease, secondary prevention of heart attack (Bradley HA, et al., 2006). Besides that, metoprolol is also used to treat migraine headaches, panic disorder, anxiety and hyperthyroidism (Cleland JGF, et al., 2002). It is a selective beta-1-blocking agents which do not significantly affect respiratory function or antagonize salbutamol effects in patients with COPD (Fogari R, et al., 2001). Metoprolol does not significantly affect FEV1 or FVC at a dose of 200 mg daily when compared with placebo in patients with moderately severe COPD and significant reversible component (Fenster PE, et al., 1990). Metoprolol is used to decrease symptoms such as rapid heart rate, sweating and tremor which are associated with thyrotoxicosis. It is also used to prevent migraine, although it is not fully understood how metoprolol works in this area (Erdmann E, et al., 2005). At low doses, cardioselective beta blockers such as metoprolol selectively block the beta receptors found in the heart and are less likely to cause side effects. These medications may be better than nonselective beta blockers for people with obstructive lung disease, asthma, poor circulation, diabetes, and depression (Torp-Pedersen C, et al., 2007). Based on the analysis of the COMET (Carvedilol Or Metoprolol European Trial) study, metoprolol patients had a 34% lower risk of death than placebo patients. Metoprolol reduced mortality and all-cause hospitalization by 19%. All-cause mortality plus hospitalization for heart failure went down 31%. All-cause hospitalization alone was lowered by 13%, hospitalization for all heart-related causes by 20%, and hospitalization for worsening CHF by 32% ( Woolfenden J,et al, 2003). Selective beta-1-adrenergic blockade is routinely preferred to non-selective blockade in patients with coexistent COPD and CHF to minimize the risk of inducing bronchoconstriction (Abraham T, et al, 1983). Compared to metoprolol tartrate, carvedilol reduced the total days lost. This effect was mostly due to increased longevity. Metoprolol tartrate has been shown to improve well-being after myocardial infarction (Olsson G, et al,1993). Beneficial effects of metoprolol in idiopathic dilated cardiomyopathy, indicating that the effect of carvedilol was in addition to that of an active control (Waagstein F, Bristow MR, Swedberg K, et al, 1993). 5.3 Propranolol From the graph, propranolol is one of the least used in Klinik Kesihatan Greentown. Propranolol is used most often for the treatment of high blood pressure, angina, and abnormal heart rhythms. It is also used to treat the symptoms of anxiety. Propranolol was the first beta-blocker available in the United States. Beta-blockers are drugs that interfere with nerve signals transmitted by the chemical norepinephrine. They reduce the force and speed of the heartbeat and prevent dilation of certain blood vessels. These actions reduce the work load on the heart, relieve the muscle tremors that often accompany anxiety, and reduce the blood pressure in the brain to prevent migraines.  ( Division of Simon and Schuster 1230, avenue of the Americans New York, NY 10020). Because of the risk of side effects, propranolol should be used with caution in people with impaired kidney or liver function (Division of Simon and Schuster 1230, avenue of the Americans New York, NY 10020). It works by affecting the response to nerve impulses in certain parts of the body, like the heart. As a result, the heart beats slower and decreases the blood pressure. When the blood pressure is lowered, the amount of blood and oxygen is increased to the heart. Propranolol is also affects the bodys sugar metabolism, it should be used with caution in people with diabetes or hypoglycemia (low blood sugar). Propranolol may mask certain clinical signs of thyroid disease and interfere with thyroid-function tests. Similarly, propranolol may interfere with tests for glaucoma  ( Division of Simon and Schuster 1230, avenue of the Americans New York, NY 10020).   Propranolol is thus used for the symptomatic relief of thyrotoxicosis (hyperthyroidism). It has no direct effect on the cause, namely overproduction of thyroid hormones, which requires to be treated concurrently. This is clearly shown at Klinik Kesihatan Greentown because most of propanolol usage was to treat thyrotoxicosis. Scores on various subjective rating scales showed that propranolol had a larger mood elevating effect than atenolol. Heart rate and blood pressure were significantly reduced 24 h after atenolol medication; these effects were absent or reduced after propranolol had been given (A.  A.  Landauer, et al., 1978  ). 5.4 Bisoprolol From the graph we know that the total usage of bisoprolol is only 6 patients out of the 3 month that we have evaluated. It shows that bisoprolol is also less than one of the least used in Klinik Greentown Ipoh. This is due to the price of the medicine. As in a journal, the greatest absolute cost discrepancy for both groups was under-estimation of linezolid ($800 and $400) and over-estimation of clopidogrel ($60) and bisoprolol therapy ($62) by residents and pharmacists, respectively (Wilbur K., 2009). It shows that bisoprolol is one of the expensive Beta blocker drugs compared to the others of Beta blocker drugs. Perhaps it cant give the same effect of atenolol which the most used Beta blocker. Based on a journal, serious adverse effects (e.g. serious bradycardia or hypotension) occurred in 3.1% of patients switching from metoprolol tartrate to carvedilol, and 2.3% experienced worsening heart failure. In the metoprolol to bisoprolol group, worsening heart failure occurred in about 2% of patients. Serious adverse effects also occurred in about 2% of the metoprolol to bisoprolol patients. Adverse effects were higher in patients switched to the equivalent dose rather than half the equivalent dose. (Pharmacists Letter / Prescribers Letter, 2009) Other than that, bisoprolol is also difficult to get the stock of drugs because it is the List A drug and have its own procedures to make the ordering from the company. 5.5 Carvedilol From the graph we can conclude that carvedilol have the least favorable number of usage compare to others beta blockers but then its still a preferable drug for physician to prescribe due to its beneficial effect. First of all, carvedilol is proven to lower mortality in patients with mild to severe congestive heart failure (Keating GM, 2003), besides it also suppresses atrial as well as ventricular arrhythmias (McMurray et. al 2005) and it is the only beta blocker shown to reduce mortality in post-MI (Mark Helfand et. al, 2007). But then on the other side, when compare to metoprolol, it is lack in improved exercise capacity (Mark Helfand et.all 2007) and it may adversely affect recovery from severe hemorrhagic shock (Taniguchi T et.all 2009). Between, patients with CHF and asthma tolerated carvedilol poorly and yet, asthma still remains a contraindication to beta-blockade. All the prescribing for beta blockers in Klinik Kesihatan Greentown also mostly due to the restriction of cost w here carvedilol is listed as A list drug therefore it needs a specialist to start and indirectly reduce A listed drug. 5.6 Labetalol From the graph, we can see that labetalol shows the least usage in Klinik Kesihatan Greentown. This is because the main indication of labetalol is for use in pregnancy complicated by hypertension with apparent freedom from maternal and fetal side-effects, and consequent improved perinatal mortality (C A Michael, 1979). Beside that, labetalol should be avoided in asthmatic patient because it produced more bronchial blockade than atenolol (A D Mackay, et al., 1981) and reduced the effect of inhaled salbutamol on FEV1 (S H Jackson D G Beevers, 1983). Furthermore, labetalol was associated with a significant less reduction or increase in cardiac output than on pure beta blockers (Lund-Johansen P, 1983) and probably induced SLE syndrome (R. C. Brown, et al., 1981). Lastly, considerable differences in dose (atenolol 138 +/- 13 mg daily; labetalol 308 +/- 34 mg daily; metoprolol 234 +/- 22 mg daily), labetalol will required a higher dose to produce similar antihypertensive effects (J J McNe il W J Louis, 1979) and the cost for labetalol is higher than atenolol and metoprolol. CHAPTER 6:  CONCLUSIONS Finally, we can conclude that atenolol have the highest usage among beta-blockers in Klinik Kesihatan Greentown followed by metoprolol, propranolol, bisoprolol, carvedilol and the least usage which is labetalol. Commencing from this study, we found that further studies is needed so that physician can prescribe more convincingly and led to a better life for patients.

martin luther king :: essays research papers

History is indeed made up of significant events which shape our future and outstanding leaders who influence our destiny. Martin Luther King's contributions to our history place him in this inimitable position. In his short life, Martin Luther King was instrumental in helping us realize and rectify those unspeakable flaws which were tarnishing the name of America. The events which took place in and around his life were earth shattering, for they represented an America which was hostile and quite different from America as we see it today. Martin Luther King, Jr. catapulted to fame when he came to the assistance of Rosa Parks, the Montgomery, Alabama Black seamstress who refused to give up her seat on a segregated Montgomery bus to a White passenger. In those days American Blacks were confined to positions of second class citizenship by restrictive laws and customs. To break these laws would mean subjugation and humiliation by the police and the legal system. Beatings, imprisonment and sometimes death were waiting for those who defied the System. Black Americans needed a Martin Luther King, but above all America needed him. The significant qualities of this special man cannot be underestimated nor taken for granted. Within a span of 13 years from 1955 to his death in 1968 he was able to expound, expose, and extricate America from many wrongs. His tactics of protest involved non-violent passive resistance to racial injustice. It was the right prescription for our country, and it was right on time. Hope in America was waning on the part of many Black Americans, but Martin Luther King, Jr. provided a candle along with a light. He also provided this nation with a road map so that all people could locate and share together in the abundance of this great democracy. We honor Dr. Martin Luther King, Jr. because he showed us the way to mend those broken fences and to move on in building this land rather than destroying it. He led campaign after campaign in the streets of America and on to the governor's mansion - even to the White House - in an effort to secure change.

Essays --

You maybe, as many people are curious of where online shopping came from? When did it start? Did someone invent it? And how was it created? In 2011, Michael Aldrich published a claim that he had invented online shopping in the United Kingdom in 1979, using a standard dial up telephone line. He connected a modified domestic television to a real-time transaction processing computer to create the Aldrich system. During 1980s he launched the Redifon's Office Revolution that allowed the consumers, distributors, suppliers and companies to be connected on-do business transactions. From 1980 onwards, the system is only used for business to business system and transaction only but during the widespread availability of the internet and computer systems during the 1990s the business to consumer online shopping started to become financially viable. (Michael Aldrich Archive. 2011) Online or e-shopping is a part of e-commerce and a process that allows the consumers to buy products, information and services through the internet. Since the generation today has high technology, it is one of the factors that encourage the people to do online shopping, rather than doing the traditional way of going to the market and store. (Gans. 2011) Shopping online is fast growing to be part of our everyday lives. Increasingly people are using the convenience of online shopping due to people having computers in the home along with high speed connection. Online shopping and visiting an online shop enables the customer to search, find, order and pay for the products, information and services that they need. To be able to do online shopping, one must visit an online shop, like a website or an account in the social networking sites that sells products. The payment o... ...s that online shopping undergoes is revealed. The diagram shows simplicity and can be easily done, that’s why people tends to be an online shopper now a days. Online shopping offers a lot of benefits for the customers. The researcher used different methods of collecting information that was used in this research paper. The researcher gathered information in the internet and in the library. They visited different reliable and credible websites and looked for recent articles and data that were used for the betterment of this research paper. The researchers did a survey to gather some numerical data about the customers who are engaged into online shopping. They did random sampling and gave out approximately 50 survey papers to different people aged from 14-30. These methods where used in order to make this research paper about online shopping credible and factual.

Television - Lost in the Unreal World of TV :: Media

Lost in the Unreal World of TV In our modern society, two separate worlds exist. The first, the world of reality, is where most of our important life experiences take place. The second, however, is where nothing substantial exists. Nothing there can have any direct impact on our lives. This is the world of the unreal; the world of television. Television lures people in with wonderful stories that have very little or no application to the real world. Instead of teaching about how the world works, it replaces healthy human interaction. When people watch television, they receive only input. This does not help them deal with other people, because it does not train them to respond. Doing things with other people is necessary to develop social skills, which must be used every day. Television does not provide any workable context for behaving around people. Everyone knows that television shows are designed to be entertaining, not to show how actual people will react to certain situations. When a person watches television, a mind is wasted. That person is throwing away time which could be used for a number of productive tasks. Which person, when asked what they did in life that was really important, would reply "I watched as much television as I could!"? As similar their names might sound, a television is not like a telephone. A telephone connects two people's minds to each other, while a television only sends pictures and sounds to one person's eyes and ears. In fact, if you let television affect your mind too much, it can cripple your imagination. You might have more images stored in your mind, but you will be out of practice for generating new ideas. Television does not provoke original thought. Sometimes television is deceiving because the watcher feels connected to a character on the screen. The observer begins to mimic the character's emotions, and feels satisfied at the end of the episode, as if something had really been accomplished. What the viewer feels is just the opposite of what has happened.

Rationality of the research

  Tourism is one of the largest industries in UK, apart from generating employment both directly and indirectly to large number of people; it is also a source of foreign exchanges for UK government.The net worth of  Ã‚   tourism is approximately  £63.83 billion and it employs more than 1.5 million people about 7 percent of all employment in restaurants, travel agencies museums, and pubs.Apart from being one the largest, tourism has also become number one online segment. The number of travelers who use the   internet for travel-related purposes have continued to increase daily. Latest data from Internet World Stats reveal that world’s internet users have reached approximately 1.17 billions with UK ranks 7th in the world with approximately 37.6 millions internet users.2Therefore, with the increase in the numbers of travelers that book online, tourism has continued to experience booming in sales.People now book rooms, buy tickets and make hotel reservation online. Recent announcement from British Hospitality Association revealed that the UK Economy benefited from tourism in 2004 to the tune of  £81.5 billion.Thus web presence has now become an essential factor in the growth of tourism industry, therefore the use of website to search for necessary information has been on the increased tremendously. Nevertheless, the design of website is a key issue for the tourisms organization and it has become an indispensable tool in making revenue for many organizations.The information gathered from 2005 Market Report revealed the number of people engaging in electronic commerce in UK is increasing yearly.4

Generic Strategy – Porter

THEME 8: GENERIC STRATEGIES 1. Introduction. 2. The Porter's approach: competitive strategies (cost advantage, differentiation advantage and specialization). 3. The Ansoff's approach: the Growth Matrix (market penetration, product development, market development, and diversification). 4. An integrating approach.  © Alfonso VARGAS SANCHEZ 1 Hope is not a strategy, specially when internationalizing the company is the intention 2 Strategic Analysis: Compulsory Questions What business is the organisation in? manufacturing/retail, etc. Who do they compete with, and how do they compete? Who are the organisation’s stakeholders?Key stakeholders & their influence. What are the external drivers for change? – PEST model, macro environment. – Five Forces model, micro/industry environment. How does the organisation gain value? – Resource audit, tangible & intangible. – Value Chain and Value System analysis. Assess the balance in the corporate portfolio, BCG ma trix. How should I compete? Porter’s generic strategies: low cost, differentiation, specialization. What are my strategic movements? Mergers/Acquisitions, etc. 3 Mission – Vision – Values PEST analysis Competitive Forces P. C. Industry Attractiveness S C. C. S. P. B (threats & opportunities)Value Chain: activities & linkages F. I. T. D. HH. RR. PR. Value System (linkages): other SBUs (synergies) & suppliers buyers’ value chains Strategy formulation, at three levels: C–B–F Company’s Competitive Position (Resourcebased View): cost advantage or uniqueness (strengths & weaknesses) I. L. OP. O. L. M&S A-S. S. STRATEGY ELEMENTS LEVELS BUSINESS SCOPE RESOURCES & CAPABILITIES COMPETITIVE ADVANTAGES SYNERGIES CORPORATE (1) (1) (1) BUSINESS (2) (2) (2) FUNCTION (3) (3) 5 STRATEGIC ADVANTAGE PORTER’S APPROACH Exclusivity perceived by the customer Position of low costs COMPETITIVE SITUATIONBroad (the whole DIFFERENTIATION sector) Reduced ( only one segment) COSTS LEADERSHIP FOCUS or NARROW SEGMENTATION 6 THE LOW COST PHENOMENON Two basic ways: -Productivity. -Economies of scale & learning/experience. 7 8 9 COSTS LEADERSHIP RESOURCES AND APTITUDES -Sustained investment of capital and favourable access to financial markets. ORGANISATIONAL REQUIREMENTS -Strict control of costs. -Detailed and frequent control reports. RISKS OR LIMITATIONS -Technological change that cancels out the experience gained or investment made. -Competitors who learn easily and rapidly. -Stagnation of the product or of the marketing. Inflation of costs that annuls the previous price differential. -Clearly defined organisation -Special aptitudes for and responsibilities. process engineering. -Incentives based on meeting -Close supervision of quantitative objectives. work and operations. -Products designed for ease of manufacturing. -Low cost of distribution. 10 Reading: â€Å"Designers on quest to build $12 computer† 11 DIFFERENTIATION RESOUR CES AND APTITUDES ORGANISATIONAL REQUIREMENTS RISKS OR LIMITATIONS -Significant aptitudes -Coordination between the functions of R&D, product in marketing and in product engineering. development and marketing. Strong investment -Qualitative assessments in R&D. and incentives. -Prestige in quality -Capacity for and technology. understanding the market -Full cooperation of and how it changes. the distribution -Appropriate channels. organisational structure for -Long tradition in the stimulating and rewarding sector, or a unique creativity. combination of aptitudes obtained in other business activities. -Competitive levels of product prices, in accordance with a strategy of minimum global cost. -The customers no longer value the product's factors of differentiation. -As the industry matures, imitation reduces the perceived ifferentiation. 12 Mention some brands for which you are willing to pay a premium price 13 SPECIALISATION RESOURCES AND APTITUDES -Resources and aptitudes of special application and interest in the company's area of operation. -Dominance of the relevant technology and of the engineering of the product. -Marketing capacity. -Ability in the use of limited resources. -Other competitors are specialized in part of the market of the already specialized company. ORGANISATIONAL REQUIREMENTS -Flexible and efficient organisation structure. -Corporate culture relevant and specific to its areas of specialisation (products and markets).RISKS OR LIMITATIONS -The differences in costs compared with nonspecialized companies are so wide that the advantages of specialisation are eliminated. -Close coordination between -The market in which the functions. company is specialized reduces its differences -Rapid response to changes with respect to the global market. in the environment. 14 15 16 A niche strategy within a declining industry Reading: â€Å"Cassettes linger long after expected demise† 17 Segmentation variables Varieties of products. Types of purchas er. Distribution channels. Geographic areas. Example: olive oil market. 18Segmentation matrix (1) TYPE OF PURCHASER VARIETIES OF PRODUCTS (QUALITY) Olive Oil Virgin Olive Oil Extra Virgin Olive Oil Final customer (bottled product) Restaurants, etc. (bulk product) 19 Segmentation matrix (2) TYPE OF DISTRIBUTION CHANNEL VARIETIES OF PRODUCTS (QUALITY) Olive Oil Virgin Olive Oil Extra Virgin Olive Oil Generic Specific 20 Combining segmentation matrixes (1+2) TYPE OF DISTRIBUTION CHANNEL VARIETIES OF PRODUCTS (QUALITY) Virgin Olive Oil for final customers (bottled product) Extra Virgin Olive Oil for final customers (bottled prod. ) Generic Specific 21 Segmentation matrix (3)GEOGRAPHIC AREA VARIETIES OF PRODUCTS (QUALITY) Virgin Olive Oil for final customers using a generic distribution channel Extra Virgin Olive Oil for final customers using a specific distribution channel National Market (a) International Market (c) (b) (d) 22 The choice of a segment/s ATTRACTIVENESS: within the same i ndustry there are segments with different levels of attractiveness. INTERRELATIONSHIPS: choose the most beneficial combination of segments. SUSTAINABILITY: your business scope should lead to a strong (defensible) position. (1) Structural attractiveness (competitive forces). (2) Size and growth. 3) Position of the company. (4) Advantages in costs or in differentiation. (5) Costs of coordination, of commitment and of inflexibility. Against: (6) Competitors with broader objectives. (7) Imitation. (8) Substitution. 23 Example: olive oil market SEGMENTS / CRITERIA ATTRACTIVENESS INTERRELATIONS SUSTAINABILITY (1) (2) (3) (4) (5) (6) (7) (8) (a) (b) (c) (d) 24 Criticisms of Porter’s framework Hybrid strategies could be employed without â€Å"stuck in the middle†. Cost leadership alone does not sell products. Differentiation strategies can be used to increase sales volumes rather than to charge a premium price.Price can sometimes be used to differentiate. A â€Å"generic† strategy can not give a competitive advantage. Arguably, the resource based strategy has superseded this generic strategy framework. 25 â€Å"A company must produce at low cost, while also innovating; it must deploy the massed resources of a large corporation, while showing the entrepreneurial flair of a small start-up; it must achieve high levels of reliability and consistency, while also being flexible† (Grant, 2012). 26 OPTIONS FOR GROWTH ANSOFF’S APPROACH CURRENT PRODUCTS NEW PRODUCTS ANSOFF’S APPROACH CURRENT PRODUCTS NEW PRODUCTS CASE STUDY:CURRENT MARKETS Market Penetration Product Development CURRENT MARKETS Expansion†¦ †¦of Products NEW MARKETS Market Development Diversification NEW MARKETS †¦of Markets Diversification 27 The Growth Matrix Sub-strategies Existing Market Penetration: -Intensification. -Relaunching. -Imitation. -Reduction of costs/prices. -Disaggregation. Product Development: -New products (R&D, innovation). -New product lines. -New services. MARKETS New Market Development: -New territoriesINTERNATIONALIZATION. -New segments of purchasers. -New distribution channels. -New possibilities for utilization. Diversification: -Concentric (or related). By conglomerates (or unrelated). Existing PRODUCTS New 28 INTERNATIONALIZATION & GLOBALIZATION 29 INTERNATIONALIZATION & GLOBALIZATION Reading: â€Å"China’s budding food industry faces scrutiny† 30 International Strategy Opportunities and Outcomes Identify International Opportunities Explore Resources and Capabilities Use Core Competence Strategic Competitiveness Management Outcomes Problems and Risks International Strategies Increased Market Size Return on Investment Economies of Scale and Learning Location Advantage International Business-Level Strategy (*) Multidomestic Strategy Global Strategy Transnational StrategyModes of Entry Exporting Licensing Strategic Alliances Acquisition Establishment of New Subsidiary Higher Performance Returns Innovation (*) Low cost or Differentiation. Standardization vs Adaptation. Multidomestic vs Global. Management Problems and Risks Strength of Market Drivers Aircraft Computers Automobiles Soft Drinks Toothpaste Retail Banking Book Publishing Baked Goods Low Multidomestic High Global Strength of Cost Drivers Pharmaceuticals Aircraft Computers Automobiles Toothpaste Retail Banking Baked Goods Soft Drinks Low Multidomestic High Global Corporate-Level International StrategiesMulti-Domestic Strategy Strategy and operating decisions are decentralized to strategic business units (SBU) in each country. Products and services are tailored to local markets. Business units in each country are independent of each other. It assumes markets differ by country or regions. Focus on competition in each market. Prominent strategy among European firms due to broad variety of cultures and markets in Europe. Corporate-Level International Strategies Global Strategy Products are standardized across national markets. Decisions regarding business-level strategies are centralized in the home office.Strategic business units (SBU) are assumed to be interdependent. Emphasizes economies of scale. Often lacks responsiveness to local markets. Requires resource sharing and coordination across borders (which also makes it difficult to manage). Corporate-Level International Strategies Transnational Strategy Seeks to achieve both global efficiency and local responsiveness. Difficult to achieve because of simultaneous requirements for strong central control and coordination to achieve efficiency and local flexibility and decentralization to achieve local market responsiveness. Must pursue organizational learning to achieve competitive advantage.International Corporate Strategy When is each strategy appropriate? High Global Strategy Need for Global Integration Transnational MultiDomestic Low Low High Need for Local Market Responsiveness Effective Standardization Coca-Cola McDonalds Barbie: The †Å"All-American† Girl Goes Overseas Barbie is more than 40 years old. Sold in 130 countries. National adaptations: – Physical features. – Costumes. – Activity sets. Standardized physique: – Scaled to 6’2†, 110 lbs. – 38-18-28. Effective Adaptation McMutton Pie in Australia. Wendy’s shrimp sandwich in Japan. Campbell’s noncondensed soups in the UK. Coca-Cola’s 175 ml containers in Japan.Cadillac Seville 1997 Asian edition: Right-hand drive, shorter seats, closer pedals, 10† shorter & retractable mirrors. Limits to International Expansion (beyond political and economic risks) Management Problems Cost of coordination across diverse geographical business units. Institutional and cultural barriers. Understanding strategic intent of competitors. The overall complexity of competition. DIVERSIFICATION Why? Growth, Profitability and Risk Reduction: Don‘t put all your eggs in one basket !! 42 DIVERSIFICATION Three essential tests for judging diversification (Porter): -The attractiveness test: Is the target industry attractive?Use the 5forces model to assess its attractiveness. -The cost-of-entry test: Is the cost of the diversification worth it? Will the diversified firm create enough additional value to justify the cost? -The better-off test: Does the diversification move produce opportunities for synergies? Will the company be better off after the diversification than it was before? How and why? Potential advantages: 1. Economies of scope (cost savings from using a resource in multiple activities carried out in combination). 2. Internal market (for capital and staff). Reading: â€Å"Perils of diversification†. The era of diversification, 50s-80s. – Refocusing, 90s-onwards. 43 DIVERSIFICATION Because of its high risk, many companies attempting to diversify have led to failure. However, there are some good examples of successful diversification: -Virgin Group moved from m usic production to travel and mobile phones. -Walt Disney moved from producing animated movies to theme parks and vacation properties. -Canon diversified from a camera-making company into producing an entirely new range of office equipment. 44 DIVERSIFICATION Reading: â€Å"Toyota tunes up violinplaying robot† 45 Diversification & PerformanceThe findings of empirical research: How do diversified firms perform relative to specialised firms? -No consistent, systematic relationship has been emerged. -High levels of diversification are associated with deteriorating profitability. -Timing is key. Does related diversification outperform unrelated diversification? -Diversification into related industries should be more profitable than diversification into unrelated industries. -Peters and Waterman’s golden rule: â€Å"Stick to the Knitting†. Empirical studies have defined relatedness in terms of similarities: Operational relatedness.Strategic relatedness. 46 Related Di versification Businesses are distinct but their value chains possess strategic â€Å"fit† in operations, marketing, management, R&D. distribution, labor, etc. Therefore, they tend to exploit economies of scope. Tend to (historically) outperform unrelated diversifications. 47 Unrelated Diversification No common linkage or element of strategic fit among SBUs — i. e. , no meaningful value chain interrelationships. Dominant logic: spreads businesses risk over multiple industries, stabilizing corporate profitability (in theory).Strategic approach: any company that can be acquired on good financial terms & offers good prospects for profitability is a good business for diversification. Conglomerates (clusters of businesses under central, mainly financial, management control), such as GE. 48 Example: GE â€Å"Diversification helps to strengthen General Electric; when one business is going badly, the other goes well, which contributes to the stability and growth of the company †. These words of Ricardo Artigas, Vice President of the General Electric Company, clearly reflect the sense behind this trategic option, the result of which is a company configured into twelve divisions: 1. Aircraft Engines; 2. Appliances (domestic electrical appliances); 3. Capital Services (financing services for customers); 4. Lighting; 5. Medical Systems; 6. NBC (television channel); 7. Plastics; 8. Power Systems (electrical energy generation); 9. Electrical Distribution and Control (power cables, transformers, etc. ); 10. Information Services; 11. Motors & Industrial Systems; 12. Transportation Systems. 49 AN INTEGRATING APPROACH Leadership in costs Differentiation Maintenance Growth Restructuring Internal External ExpansionDiversification of Products of Markets Concentric Conglomerate Vertical Integration Horizontal Integration 50 AN INTEGRATING APPROACH GROWTH STRATEGIES Expansion Internal Diversification Expansion External Diversification of Products of Markets Concen tric Conglomerate of Products of Markets Concentric Conglomerate Strategic Advantage Costs Differentiation Readings from the textbook: Pascual & Lagasa -internal growth based on diversification-; Fontaneda & La Casera -external 51 growth based on the expansion of products and markets-. â€Å"Progress is when things get simpler, not more complicated† Bruno Munari, Italian artist. 52