KFC Exploring Strategy Essay

Summary You are introduced to KFC organization. A fast-food chain restaurant comes from North Corbin, Kentucky that featuring fried chicken. KFC is recognized as the best fried chicken with its original 11 herbs recipes and produce most fried chicken to the world. What makes KFC still remain strongly while other companies are struggling to find a spot in the market? To answer this question, you will be finding out KFC strategic profile, vision, mission and values that is created and brought towards customers. Understanding the company strategic development and how the Corporate and Business level create and develop strategies and knowing what your competitors are doing. We will acknowledge about its customers perception, innovation and international strategy. What has KFC been doing to innovate its staffs, how innovation is created, what changes the companies has made and how did it result. The strategy analysis and main focus on home country – competitive advantage developed from hom e country. At the end of this report, you will be able to perceive the organization values in order to create competitive advantages that make the business sustainable in the presence and future. 1.0 Introduction 1.1 Background KFC (originally known as Kentucky Fried Chicken) a subsidiary of Yam! Brands. Together with Taco Bell, Long John Silver’s and Pizza Hut they are forming the world’s largest restaurant system with more than 32,500 outlets in 118 countries worldwide. KFC was founded by an entrepreneur named Harland Sanders in North Corbin, Kentucky, 1930. He started by selling fried chicken at his roadside restaurant during The Great Depression and discovered the potential of fast-food restaurant franchising concepts. Since then he expanded his first franchise market in Utah and foreseen a rapid successful business. 1.1.1 Company Vision/Mission/Objective The company’s vision statement is to be â€Å"To be the leading integrated food services group in the ASEAN region delivering consistent quality products and excellent customer-focused service†. Its purpose is to bring people from all religions, ages and backgrounds together to enjoy good food, ‘proper food at reasonable prices’ KFC mission is about reasons to â€Å"Celebrate their achievements of others and have funs doing it† by customers focus and belief in people. â€Å"Recognition is everybody’s responsibilities† (Adonis Chapel, 2008) In achieving its vision and mission KFC plans to offer a healthy menu to customers. Providing customers with their best and making customers with smile every time they eat at KFC in order to make repeated and potential customers. On the other hands, all associates need to be trained to be customers maniacs. KFC has invented some options for healthier choices to meet different types of customers and expectation. They still continue to expand their business to get more customers purchasing their food 1.1.2 SWOT (www.business-docs.co.uk/documents/swot-analysis-template) Below table is SWOT analysis of KFC in 2013 Strengths KFC has earned the second largest sales in 2013 among those fast-food restaurants Secret homemade 11 herbs recipes First western food style to establish in China Subsidiary of the second largest fast-food in the world together with of KFC, Pizza Hut and Taco Bell Offering the most original and the advantage of market leader among restaurants offering chickens as their primary menu Weaknesses Too many anonymous suppliers that caused the excessive antibiotics in used chicken Experience high employee turnover as they always short of long term staffs Unhealthy menu, most of items are deep fried Not focusing on advertisement campaign Negative publicity Weak in marketing effects Opportunities Innovation on healthy menu in order to target different type of customers Providing customers’ needs by offering 24hour services, drive through and home delivery Expending on the variety of food choices, not only chicken Potential growth in Asian countries such as Vietnam, Malaysia and Philippines Threats Lawsuits against the company for its unsafe chicken Consumers are more concerned about their health and tend to reduce on fast and oily food Ups and downs currency rates in different countries More people are following the trend of healthy eating 1.1.3 PESTEL (www.dineshbakshi.com/igcse-business-studies/external-environment/revision-notes/63-external-environment-factors) KFC combines three major elements PESTEL which are P- Political: KFC political analysis is their directive to run the restaurant. They use politics to solve the problem. Because the claim of excessive antibiotics in chicken. They made a loss in their profits. CEO of Yum Chinese operations apologized to the public for the mistake and did a makeover menu for China to revive its sales and image. S- Social: analysis which supports the operation’s progress. It may involve culture, values, norms, behaviour and belief of a particular country and they have social activities for the environment. Malaysia is a Muslim country. In order to understand and satisfy its people, KFC has cut off the other meat in their menu. 100% chicken used is Halal certificate. It is a way to respect a country’s religion and its people. T- Technological: the most important element in order to be competitive and follow up your competitors and trends. Without modern technology a company will collapse in the market. KFC was the first to introduce new baking system in their restaurant. Preparation process which involves cooking, frying and all other works are seen in front of customers. 1.2 Strategic Development How does KFC create and develop strategies (www.functionformulabusinessstrategy.blogspot.sg/2010/10/strategic-visioning.html) 1.2.1 Corporate Level Headquarters are located in Louisville, Kentucky. Working as a whole organization at the corporate level, its headquarters first made KFC as a basic model focusing on limited menu, low price meals and convenience. Chairman and CEO of Yum!, David C. Novak is in control of the operations. He makes most important decisions that will affect the whole organization. His key focus are 1) build leading brands across China in every significant category; 2) drive aggressive international expansion and build strong brands everywhere; 3) dramatically improve U.S. brand positions, consistency and returns; and 4) drive industry-leading, long-term shareholder and franchisee value (source: Taking people with you, David Novak, 2007) 1.2.2 Business Level In 1987 KFC was the first western restaurant to open in China; the brand has since grown rapidly throughout the island. KFC adapts its menu internationally to suit regional tastes, and there are over three hundred  KFC menu items worldwide. The company is now the largest restaurant chain in China. Sam Su is the chairman and CEO of Yum!’s Chinese operations. At the Business Level, the regional executive must have the understanding in the taste and culture of its country, to make some changes from the original menu that will satisfy the citizen but won’t affect the Corporate Level menu. Other than chicken, KFC in China is serving pork and skewers as well. Still keeping the original fried chicken but adding more items to interest customers and more various selections. Porridge is also being served because Chinese used to believe that eating a hot bowl of porridge in the morning is good for health and it is not too heavy. By inventing more items on the menu, Sam Su has on ly not targeted to the young people, but also people at different ages. Menu includes an average of 50 different menu items per store as he believes different people have different tastes. 1.2.3 BCG Besides fried chicken, KFC is also known for its delicious Zinger burger, which is at Star and the second best selling in store. Zinger burger is high for both market share and growth. Rice and Spice, newly invented item, high for market share but low growth. Twister is low for market share but high for market growth, certainly public acceptance. Arabian rice is low at both market share and growth. Today we hardly see it on the menu as it has recently removed. (www.download-reports.blogspot.sg/2011/09/new-product-development-at-kfc.html) 1.2.4 Porter’s 5 forces framework for KFC (www.hbr.org/2008/01/the-five-competitive-forces-that-shape-strategy/ar/1) Force 1: Power of Suppliers Suppliers are in control of providing KFC’s raw materials. Suppliers have the right to decide whether they still want to carry on contract with buyer. Any other buyers want to duplicate KFC menu they can just approach this supplier and offer a better price. If the supplier cut off the contract KFC will lose its market. Force 2: Power of Buyers KFC is in charge of making decision of which suppliers to get from. The amount of poultry used for KFC daily use is numerous. So suppliers must be able to supply the necessary amount without fail and ensuring that their raw materials are hygiene standard. Last year in China, KFC was having problem with its suppliers for the excessive antibiotics used in chicken. KFC immediately cut off more than 1,000 their suppliers after the scandal has affected the company’s image. Force 3: Threat of new Entrants New entrants are companies that recently enter in the same market and provide the same food. Radix Fried Chicken also specializes in fried chicken and has grabbed customers’ attention by switching their taste. Radix Fried Chicken was found in 2013 while KFC has started since 1930. Force 4: Threats of Substitute or Services Popeye’s is known for Louisiana kitchen. Their menu and taste are mostly similar to KFC. While KFC is specialised for its chicken Popeye’s also offer customer few seafood choices such as tempura and shrimp. They also invent biscuit and chicken mashed potato on their menu. Popeye’s is also offering free Wi-Fi. Force 5: Rivalry among existing competitors McDonald’s is KFC strongest competitors which also offering its menu items similar to KFC. Speed of service is extremely competitive and set meal price is mostly the same. McDonald’s has been offering its drive thru and 24hour services for years when KFC just recently tried out but only available in certain places. 2.0 Critical themes 2.1Customers (www.imeeta.wordpress.com/2012/04/27/business-strategy-bowmans-clock/) As evaluated, KFC is at position 3 which is Hybrid (moderate price and  moderate differentiation). Menu items offered like fried chickens, burgers, wings, drumsticks, side dishes, carbonated beverages and desserts are similar to other fast food restaurants such as McDonald’s, Popeye’s, and Burger King. Services are at tip stop speed comparing to other restaurants in the fast-food chain. KFC is always public acceptance and first option when they think of the phrase â€Å"fried chicken at an affordable price†. 2.2 Innovation In order to achieve a company’s success, staffs need to be encouraged. David C. Novak CEO and chairman of Yum! Brands, was recognized as one of the quick-serve industry’s Top 10 Most Innovative People on QRS Magazine. On his interview with â€Å"The CEO TV show- Interviewing American’s top CEO† he shared his learning while creating one of the most American products. He believed that people get excited about news and in the food business people love to try new things. The specific thing of what a CEO should do is extremely focus by looking and his own people and the way they do things. Driving innovation by getting out of the company and see what other people are doing. Listen to the voice of our customers, connect with them, and always reach for new innovations and excellence in everything they do He innovate his business by learning from his competitors in order to keep consistence. â€Å"Innovation by people’s inspiration† he said. David C. Novak devotes much of his time to personally train leadership skills for the company’s management staffs and franchisees, emphasizing teamwork and a belief in people that rewards and recognizes customer-focused behavior. In KFC there is no discrimination for old staffs. People after retirement can join KFC as a front clean-up staff. 2.3 International strategy KFC China’s global growth base on â€Å"go global, act local† by understanding the local culture, economic and regulatory differences becomes the key element to perform the business’s success. First KFC identified what the local like and dislike from customers’ feedback. Then they adapt the fast-food model to fit the local cuisine and culture. You won’t be able to find such thing called chicken with Sichuan spicy sauce, rice, egg tarts, and soybean milk on American menu. Chinese people use to in eat large group so KFC has  created larger value meal as well. They also hire local management staffs to take good care of customers and understand their way of local doing business well. The company also follows Chinese strict foreigner investment laws and in action with local producers. 3.0 Conclusion 3.1 Value KFC aims to achieve value by creating quality food at a reasonable price and convenient service. Making customer satisfaction as a priority and fulfill customer’s demands in order to meet their satisfaction. They have also developed value menu for kids and school children with lower prices, value meal and combo for large group of people to share instead of buying each person individually. Value is also created for royal staffs and who are rewarded with good customer services. 3.2 Competitive advantage KFC biggest competitive advantage is being the first fast-food restaurant chain to grow globally. They have gain popularity among years in the fast food chain featuring fried chicken. KFC is well-known for its homemade 11 herbs secret recipes and the leader market among those restaurants selling the same food. Secondly the company is in charge of setting the lowest price for others to follow. If any restaurant goes lower than that they will fail in the market share. 3.3 Sustainability For the last 84 years KFC has remained sustainable in the market. In 2016 KFC established the eco environment program by reducing the volume of water used and carbon footprint, encouraging energy efficiency and sensible material use. They have been working with Carbon Trust and to reduce their emissions. KFC is playing its part to reduce the environmental impact and protect our planet. 4.0 Recommendations Judging on the company business strategy, KFC should improve on its menu by creating for more choices of healthier food options. The purpose is to target different type of customers, customers with special needs or diet or people with obesity problems. They can offer brown rice or whole meal rice  instead of white rice, steamed chicken, boiled veggies. Or they can follow up with McDonald’s by offering KFC’s cafà ©, serving cakes, hot and cold coffee or tea, more ice cream options for the kids’ craving. In addition, they may also expand their areas for 24hour services and drive through for the convenience of late customers. References 1. The Associated Press (2011, October). Colonel Sanders secret recipes discovered; manuscript reveals KFC founder’s favorite hometown foods. Retrieved April 18, 2014, from http://www.nydailynews.com/life-style/eats/colonel-sanders-secret-recipes-discovered-manuscript-reveals-kfc-founder-favorite-hometown-foods-article-1.975651 2. Brady, D. (2012, March). KFC’s Big Game of Chicken. Retrieved April 19, 2014, from http://www.businessweek.com/articles/2012-03-29/kfcs-big-game-of-chicken 3. ENP Newswire (2014, March 28). KFC China Launches New Menu and Marketing Strategy Nationwide; Milestone Signifies Next Phase of Company’s Aggressive and Comprehensive Plan to Restage KFC in China. Retrieved April 20, 2014, from http://smart-grid.tmcnet.com/news/2014/03/28/7749628.htm 4. Harvard Business School (2011, June 17). KFC’s Explosive Growth in China. Retrieved April 20, 2014, from http://hbswk.hbs.edu/item/6704.html 5. Jurevicius, O. (2013, March 10). KFC SWOT anal ysis 2013. Retrieved April 19, 2014, from http://www.strategicmanagementinsight.com/swot-analyses/kfc-swot-analysis.html 6. Kassidy Emmerson, K. (2006, March 10). The History of Colonel Harland Sanders and His Kentucky Fried Chicken. Retrieved April 19, 2014, from http://voices.yahoo.com/the-history-colonel-harland-sanders-his-kentucky-23199.html 7. KFC Development (n.d.). Sustainability. Retrieved April 19, 2014, from http://www.kfcdevelopment.co.uk/sustainability.aspx#tab_greenfacts 8. Lencioni, P. M. (2010). The Five Temptations of a CEO: A Leadership Fable. Hoboken: John Wiley & Sons. 9. Liu, W. K. (2008). KFC in China: Secret recipe for success. Singapore: John Wiley & Sons (Asia. 10. Novak, D. (2012). Taking people with you: The only way to make big things happen. New York: Portfolio/Penguin. 11. Novak, D. (2007). The education of an accidental CEO: Lessons learned from the trailer park to the corner office.

Questions: History and Political Science

According to Max Weber, the state is distinguished from all other organizations by its monopoly on the legitimate use of force. its use of bureaucratic procedures in making policy decisions. c. its ability to communicate political information via the media. d. its dependence on culture to define social life. its hierarchical chain of command. Which of the following is NOT among the eight essential functions that must be performed by every state, according to Gabriel Almond and his colleagues? Interest articulation Political socialization Political modernization Policy adjudication Policymaking 5. A group of components that exist in a characteristic relationship and interact on the basis of regular patterns constitutes a territory. nation. state. social contract. system. 6. Liberty, equality, freedom, and Justice are examples of inputs. requisite functions of the state. values. traditions. guaranteed rights. 7.When decisions are accepted as binding by the people affected, the decision s may be described as consensual. judicial. authoritative. rational. All of the above 8. Which of the following can be a source of legitimacy for the state? Law Tradition Contract Law and tradition but not contract Law, tradition and contract 9. Which of the following actions is a â€Å"support† input to a political system? Abstaining from a local election Obeying local traffic laws Signing a petition Requesting a government service None of the above 10. A main rationale for sovereignty, according to the Debate in 5, is that it is a core principle in national constitutions. is a central premise of international law. it is essential for the effective functioning of states. it is more important than humanitarian intervention. it prevents many wars. Res publica refers to a citizen's right to privacy. a citizen's responsibility to support the government. the appropriate domain of state activity. the right of the state to protect its territory. the demands and supports directed to the political system. 12. The most important security goal of a state is autonomy. influence. dominance. survival. economic growth. 13. Which of the following is NOT a major role of the legislature? Oversight of the executive branchInterpretation of laws Representation of citizens Enactment ot legislation All of the above are major roles. 14. Which of the following is an important area of legislative oversight? Approving major executive appointments Enacting regulatory legislation Committee hearings on legislation Control of the agenda by the legislative majority 15. A legislative ombudsman is an independent agency that assists in judicial review. legislative oversight of the administration. policy implementation. supervision of the military. analyzing legislation. 16. Which of the following is a potential drawback of a bicameral legislature?Proliteration ot elections Less effective representation Stalemates in policymaking Proliferation of political parties 17. Many observers clai m that during the twentieth century the power of legislatures increased steadily. declined significantly. remained the same. increased relative to the executive but declined relative to the Judiciary. e. declined in bicameral but not in unicameral legislatures. 18. In a political system with a fused executive, one actor carries out ceremonial aspects of the executive role while another carries out more political aspects. b. a small number of people exercise collective executive leadership. c. e ceremonial and political functions of the top executive both reside in the same actor. d. 19. which ot the tollowing is most responsi countries? The legislature The administration

Can Give Rise To Psychological Issues

Explain Can Give Rise To Psychological Issues? Withholding of the truth about Amy can give rise to psychological issues and have an impact on her quality of life. Her physical inabilities as difficulty to find words and repetition during a conversation and lack of concentration are contributing to her psychological distress, as she is unable to understand the reason of her sudden change in behaviour and memory. Withholding the information can have a negative impact on the patient’s attitude. It would reduce her coping ability, cause mood disturbances and anxiety and reduces her ability to prepare for the future(Kelley & Morrison, 2015). The withholding of life limiting illness about Amy also has serious negative impact on her family. Her mother is in her 80’s and witnessing such a change in behaviour and mood in Amy can have psychological impact and extremely painful. Her son Erik finds it difficult to conceal the truth of her life limiting illness from Amy and that might affect her end-of-life care and her compliance with the treatment and medication. This puts her family members in a hard situation and her family members face ethical dilemma whether to inform her or not. This situation raises ethical dilemma for me. Although, Amy and her family members wants to withhold her life limiting illness as posed by the family, the primary concern is to disclose the illness to her in culturally sensitive manner. This ethical dilemma can affect her end-of-life care and response to treatment. As she has limited English speaking ability, it is important to convey through family members or interpreters. The considerations include using of plain language, addressing of one piece of information at a time and ask about Amy’s worries, thoughts and understandings after illness disclosure through culture centred communication (Katz & Johnson, 2013). The care provided to Amy should include her cultural practices and spiritual needs and directed towards culture-centred care. It is important for the staffs to learn about her beliefs, cultural attitudes meanings of illness, health and symptoms. As she is diagnosed with life-limiting illness, it is important to recognize the unique cultural aspects of the care provision at the end-of-life (Wittenberg, et al., 2015). Knowing about cultural values of Amy would help the staffs to understand, grapple and navigate through the limiting illness. Integration of Amy’s cultural needs would help staffs in delivering her end-of-life care. Staffs need to understand that cultural factors and their integration into healthcare would influence her healthcare seeking behaviour, medical and clinical decision-making and finally health outcomes. Therefore, culture-centred end-of-life care act as driving factor in delivering culturally competent healthcare to Amy. By providing culture-centred, care to Amy would help her and family to respond to the end-of-life care and have a positive impact on their psychological well-being. The cultural consideration and specific spiritual needs of Amy would be fulfilled in her terminal diagnosis, as the staffs would provide culturally appropriate care that improves her and family situation. As a graduate health professional, I would like to spend time to develop an understanding of her feelings and specific needs to address anxiety and point of disagreement in providing end-of-life care. I will try to develop an empathetic relationship with Amy and her family in providing culture-centred care. For this culture-centred communication, principles are important through interpreters to understand Amy’s true preferences for receiving illness information. As she has limited English speaking ability, it is important to be cognizant about how her cultural factors and beliefs might affect her end-of-life care. This sensitivity to Amy’s individual and cultural preferences would help to avoid stereotyping and in making incorrect assessments in providing her end-of-life care (Moir, Roberts, Martz, Perry, & Tivis, 2015).   Katz, R. S., & Johnson, T. G. (2013). When professionals weep: Emotional and countertransference responses in end-of-life care. Routledge. Kelley, A. S., & Morrison, R. S. (2015). Palliative care for the seriously ill . New England Journal of Medicine,  373(8), , 747-755. Moir, C., Roberts, R., Martz, K., Perry, J., & Tivis, L. J. (2015). Communicating with Patients and their Families about Palliative and End of Life: Comfort and Educational Needs of Staff RNs. International journal of palliative nursing,  21(3), , 109. Wittenberg, E., Ferrell, B., Goldsmith, J., Smith, T., Glajchen, M., Handzo, G., & Ragan, S. L. (2015). Textbook of Palliative Care Communicaiton. Oxford University Press.

Analyze the Running Case on page 331 of the textbook, The Recreation Essay

Analyze the Running Case on page 331 of the textbook, The Recreation and Wellness Intranet Project - Essay Example In order to achieve all these, many organizations have created disease management programs and health maintenance programs to improve well-being within the organization (John Bates, 2008). Other programs like mental health have been adopted as part of health promotion programs, and these have to reduce depression, stress, and muscle strain greatly. Many companies that have adopted these have enjoyed employees with less behavioral problems and reduced suicide rates among their employees as compared to companies that have not adopted this program. The program also have been of benefit to families since extensive management of stress has resulted in lower domestic hostility and reduced child abuse as well as reduced spouse abuse. Most companies that have comprehensively addressed health and safety measures in their work environment have experienced decreased injuries while working hours. Thus, only a few workers are compensated, and this reduces companies health care cost. Health and safety measures have also reduced the number of disabilities and even death in the workplace especially machine operators. Recreation and wellness program for general health in workplace show employees that they are recognized and the employer is concerned about their health. It assures them that their well being is of importance to the organization. Employees must enjoy the program because it helps them get healthier, lose weight and lower cholesterol level and lower blood pressure. I help you sleep well and utmost save money that you could have rather used for drugs. In addition, on the other hand, the wellness and recreation programs can build a sense of friendship among co-workers. It happens since one has a chance to experience outdoor activities like volleyball program, soccer program, walking program, table tennis program and even going to the gym. By positively

Emergency Medicine Concepts and Principles Research Paper

Emergency Medicine Concepts and Principles - Research Paper Example Emergencies – Emergencies, on the other hand are events which usually threaten public health, safety, and welfare (Department of Environmental Management, n.d). These incidents differ from each other in terms of size, location, and their causes, as well as impact; however, despite these considerations, they usually all impact negatively on the environment. Emergencies are also considered as unexpected events which impact negatively on the lives and properties of people, and eventually they prompt the use of community emergency and routine responses as well as procedures (Emergency Management Institute, n.d). Examples for emergencies include: forest fires, outbreaks of diseases, road blocking landslides, and floods covering towns and farms (Central Coast Center Independent Living, n.d). In Australia, in the two landslides which occurred from 1939 to 2007, about 28 individuals were killed and 101 other individuals significantly impacted (CRED, 2007). Wildfires numbering 28 were seen from 1939 to 2007, this caused the death of 300 people, and caused damages amounting to about 1.2 million US dollars (CRED, 2007). Disasters – Disasters are â€Å"a condition or situation of significant destruction, disruption and/or distress to a community† (Emergency Management Australia (2004, p. ix). In a similar vein, the United Nations (1992) consider disasters to be incidents which seriously interrupt the normal activities of society as they cause significant human and environmental losses – more than what can normally be handled by the community resources. Beachley (2005) enumerated the following as disasters: floods, extreme range of temperatures, epidemics, multiple car crashes, and environmental contamination through chemical agents. In... There are various principles and concepts which define and govern disasters and emergencies. Basically, disasters and emergencies are unexpected events which have a significant effect on various individuals and large communities. These disasters impact significantly on the lives of many people. They bring about physical as well as psychological effects. Emergency management helps authorities cope with these disasters and it helps people recover and prepare for these emergencies. Emergency management is important because most communities face a persistent hazard and risk for losses from emergencies and disasters. These hazards may come in the form of natural threats like floods, cyclones, earthquakes, and tsunamis; it also includes technological hazards like chemical, biological, and radiological threats. Australia is situated in an earthquake prone region which it at a continuous threat from earthquakes and tsunamis, as well as volcanic eruptions. It is also in a region likely to be hit by storms which lead to floods and landslides. It s humid temperature also places it at a higher risk for suffering bushfires. With adequate planning and coordination, the prevention and management of these incidents are ensured. The prepared communities are communities which have managed to make the necessary plans for these emergencies. The systems in this community are coordinated and the local as well as national agencies are linked with each other. With these plans in place, it is possible for people and communities to minimise the impact of disasters and emergencies.

Some Abortions are Immoral and Some are Moral Essay

Some Abortions are Immoral and Some are Moral - Essay Example The debate on 'Why would a mother choose to end her own child's life' is never ending. There are various moral, ethical, health and legal issues involved. Abortion not only effects mother and her baby but also the rest of the family members: father, siblings of baby, grandparents, friends and everyone else involved in the process. 1. Measure of birth control: 98% of abortions result as a measure of birth control. It is the leading cause of death in America. Since no birth control method is 100% effective, women opt for a termination in case of an unplanned pregnancy ("Abortion 101,"n.d.). 2. Teenage Pregnancy: One of the major reasons of teenage pregnancy is unawareness. Most of these pregnancies are unintended resulting from unsafe sex. Teens choose abortion as they are not prepared to become parents at such an early age of life. In 1999, over 148,000 teenage pregnancies ended in abortion. Most of the abortions are performed without the consent and knowledge of parents. The best measure to prevent the teenage pregnancy is the education about safe sex and support of parents (Alford, 2003). 3. Rape and incest: Rape and incest victims account for 1% of the abortion cases ("Abortion 101,"n.d.).Abortion is often seen as a solution to the problem. But it can have serious long lasting effects on the mother such as depression, guilt, anger, loneliness. (Reardon, 1994). 4. Single parenting: In many cases, woman's partner may not support her in pregnancy and wants to go ahead with the abortion. This leaves mother in dilemma to choose birth or abortion. Understanding the problems faced by single mothers in the society, mother may opt for an abortion ("Why Do Women Have Abortions," 2006). 5. Financial issues: Some mothers consider that they are not financially sound to support their child after birth. This situation may lead to inadequacy of indispensable resources in upbringing of the child. The future and security of both the mother and the child are at risk. Most of the times this situation is due to single parenting ("Why Do Women Have Abortions," 2006). 6. Pregnancy due to a dishonest premarital or extramarital relationship: Pregnancy resulting from an illicit relation may ruin a women's family and social life. It may have serious impact on other family members such as her husband, other children, in laws and friends. 7. Pregnancy as a hurdle in education and career: College age women form the major abortion carrying group. Pregnancy is seen as hurdle in realizing their dreams. 8. Gender selection: It is also a major cause of abortions, especially in Asian countries like India and China. Families who do not have enough funds to raise and educate many children, opt for sons who will eventually earn for the family in future and abort girl child with the fear of raising her to be married into someone's else's home. 9. Domestic violence issues: Women subjected to domestic violence in their families do not want to give birth and raise their babies in such an environment and choose an abortion over birth. 10. Birth defects detected in the babies: If the medical tests detect birth defects in the babies, mothers can opt

Project Management of the construction of an international airport in Essay

Project Management of the construction of an international airport in a developing country that involves land acquisition and fa - Essay Example Important inclusions which need attention have been emphasized; this includes the project schedule, WBs, and PID. All the construction processes have been identified together with material usage. It has also looked attest and inspection of all construction processes. Importance of good record keeping techniques have been emphasized together with what is there to be recorded and why. The project has also entailed the risk management process where all the risks have to be identified and possible solutions put down. Introduction Fast paced communication systems, restrictive budget, efficient planning, and just-in-time deliveries make projects operation easy for both the project leaders and project team. In order to keep time, construction’s players must streamline their operations in the construction, improvise ways to improve their rate of operation, shorten and innovate the construction cycle, as well as all other undertakings with in the construction process. In an internation al airport construction in a developing country, many aspects must be looked at to ensure that nothing goes wrong in the under takings. Having in mind that it is been built in an occupied land makes it complex because of the relocation policies of the land. A quality project needs adequacy in planning, efficient technology should be used, access to construction materials should be good, and the project schedule should be followed to the letter. ... Risk management is quite essential because poor risk analysis may lead to project implementation failure. WBS This is the process used in both system engineering and project management where the undertakings are broken down into smaller potion to facilitate the implementation processes. In project management, it is termed as discrete work components and facilitates the scope organization as well as definition along with availing guidelines for project control and development. Below is a sample of a WBS in an air craft system. The work breakdown in this project entail: farmers’ displacement, land acquisition, project schedule analysis, risk assessment and analysis, material acquisition, and airport construction process. The tool facilities overall frames work in the planning and control of the project as well as their implementation process (Thomas, 1996). Famers’ relocation and land acquisition Land being used in this project is under use by the farmers, the acquisition process needs fairness and use of the right channel to ensure that the displacement process has gone inline with the legal policies and ethics of the land. The best way to do this is by purchasing a land of equal productivity and relocating the farmers in that land and putting up structures for them or making compensation financially with respect to the value of the land. PID The term is used in project management to mean plan of approach. This is a series of documents containing different important documentations which include: reference terms, business case, project tolerances, risk register, communication plan, project plan, and any other important document in a quality plan. Important inclusions in the PID: Project goals – the goals of this project is construct an international

International Organisational Behaviour Essay Example | Topics and Well Written Essays - 3000 words

International Organisational Behaviour - Essay Example Sony has its operations in many countries spread across six continents of the world. It was in 1973 when this Japanese giant entered the Singaporean market and since then it has become one of the leading players of the consumer electronics market. Sony Singapore (Sony, 2011) functions include with its activities of â€Å"engineering, information technology, manufacturing, sales and marketing, treasury services, logistics and others†. Sony Singapore (Sony, 2011) employs from than 1900 employees in the country. This paper is an attempt to explore, investigate, and examine various aspects related to the organisational behaviour of Sony Singapore. Systematic study of Organisational Behaviour Systematic study of organisational behaviour refers to the scientific approach used by organisational behaviour to combine various fields of â€Å"human psychology, organisational development, management, organisational theory, human resource management, and sociology† (Champoux, pp. 29 -44, 2010). The systematic study of organisational behaviour refers to the fact that the â€Å"overall purposes of the field are understanding/explanation, prediction, and control† (Knights & Willmott, 79-81, 2006). Furthermore, the definitions provided by the field are operational and precise and the measures are reliable and valid. Psychology is the first and foremost behavioral field, which contributes to the field of organisational behaviour. It seeks to explain the behaviour of people, measure, explain, predict, and control these behaviours. Without any doubts, Sony continuously tries to find way to alter and tame the behaviours and attitudes of its employees in such a way that the organisational productivity (Champoux, pp. 421-428, 2010). Sociology is another behavioral discipline, which has a close link with Organisational behaviour. People do not live and operate in vacuum, in fact, their behaviours are continuously influenced by social factors. The organisation of So ny itself is a social institution and norms, social roles, values, and customs have constant affect on its employees and managers. Shaping Behaviours of Sales Executives Successful organisations and managers are the ones who know how to align their human resources with the organisational objectives. In other words, it is the task of the organisation and its managers to motivate and push its employees towards achieving the goals and objectives assigned to them. Following are the four possible ways in which a sales manager at Sony can shape the behaviour of it sales executives. First, in the light of the operant conditioning theory, behaviours can be shaped by presenting a reward every time the subject engages in the desirable behaviour. For example, if a sales executive is putting in extra effort to take training sessions then acknowledging his effort in front of the whole staff and applauding him could be a reward, which would reinforce that behaviour (Knights & Willmott, 79-81, 200 6). Second, other than positive reinforcement of behaviours which has been mentioned above, negative reinforcement is also an option. Like positive reinforcement, it refers to the practice of taking something undesirable in order to reward and reinforce any behaviour. For example, if a sales executive achieves the target of his monthly sales even before the last week; negative reinforc

Comparison of the Form and Style in Things Fall Apart and A Far Cry Essay - 1

Comparison of the Form and Style in Things Fall Apart and A Far Cry from Africa - Essay Example Since the story is that of a warrior, Achebe uses a tone that is martial. At the same time, the tone is also that of a historian who faithfully chronicles the events that happen in a society. The events of this society are shown through a pre-colonial and colonial perspective. The tone of Walcott’s poem, A Far Cry From Africa is different. This is because Walcott writes during a period when there is a consensus on the debates that surround pluralism and nativism, in favor of a pluralistic culture that seeks the integration of a pre-colonial and colonial culture. The agony that Walcott expresses regarding the conflict between his African belonging and the English language in which he is proficient and in which he expresses himself as a writer can be seen in the tone that he adopts in his poem which is that of a lament. These works tilt towards the pluralist cultures that the writers who were a part of the Negritude movement opposed (Ashcroft, 2010). As a result, their tone, eve n though they lament the loss of a culture with the advent of colonization, they express the hope of an integration of African and western cultures. This mixed culture may be said to be a reflection of the identities of these writers, an identity that had been molded through a consciousness of their own racial identity along with western education. Their tone enables them to make clear the racial differences that they aim to highlight through their works. These differences are made clear by talking of the conflict in the value systems that form the societies that Okonkwo lives in, in Things Fall Apart and the duality of the identity of the poet in A Far Cry From Africa. The narrator in Walcott’s poem is unapologetic about this... Comparison of the Form and Style in "Things Fall Apart" and "A Far Cry from Africa" While talking of race differences in their works, they are critical of the western colonizers for their economic policies, but occupy a space that is not entirely divorced from the western education that they have received. As a result their discussion of racial differences is extremely nuanced and complex. They however, have various differences in their tone and style, something that can be attributed to the differences in the historical and geographical context in which these writers produced their work. This paper shall attempt not only a historicist and new historicist mode of analysis, but shall seek to combine it with an analysis of the forms that the writers in question employ in their works of art. Things Fall Apart was one of the first few novels that explored the role of the colonizers in the changes that came in African society. There have been many works of art that have followed this work in the tradition of post-colonial works of art that critique the role of the coloni ser. The conflict that both these writers face is one that is faced by people, who are, according to Frantz Fanon, of mixed identities. Such people cannot turn to either side for support and thus end up feeling like outsiders in their own community. While this enables Achebe to provide his work with the perspective of an outsider, imbuing his work with the tone of a historian, it enables an effective articulation of Walcott’s identity crisis that results from not only a biologically mixed parentage but also a metaphorical one.

Strathfield Health Centre Case Study Example | Topics and Well Written Essays - 750 words

Strathfield Health Centre - Case Study Example It will also demonstrate an ability to relate key roles of information systems in improving supply and inventory activities. The point of supply chain managing is to do away with inefficiencies, mainly surplus inventory. Inventory is a barrier to uncertainty. Uncertainty is hard to predict. Partnership between supply chain allies assists to lessen uncertainty since they have a faster ability to react and adjust, but they do not eradicate it. Supply chain visibility is extremely valuable, in that, it eases uncertainty and manages inventories (Silver 7). This would make it easier for SHC to know what inventory is where in the supply chain. This should be from purchase demands to suppliers to where customer demands are collected at supply centers, the better SHC can run their inventory. People, process and skill used to manage all inventory should be examined by the SHC. The following method should be applied by the SHC management team in order to improve its supply of medical products. Plan for an improved supply system In order to manage an office supplies inventory, SHC needs recognize everything that is happening around them. The SHC team needs to look over their office supplies and determine which items are mostly used in the health centre. Secondly, the team needs to create a list of items that if they lacked at any moment it would lead to a halt of the business. SHC should store a reasonable amount of these medical supplies in case a shortage arises. They will bring efficiency around the health care centre. The SHC team should also maintain a list of the required supplies to save them the energy and time of preparing a new list every time they want to order medical supplies. They should look over the list of supplies on a weekly basis to update it and make sure that all medical supplies that the health centre requires are within their reach. Key roles of Information Systems in improving supply and inventory processes An information system (IS) refers to any blend of information technology and an individual’s actions that sustain management, operations and making of decisions. It is also referred to as an application landscape (Rainer 3). In an exceptionally wide logic, the phrase information system is normally used to refer to the communication between processes, people, technology and data. In this view, the expression is used not only to refer to the ICT that an organization employs, but also to the means in which individuals in the organization can work together with this technology in support of business activities (Rainer 45). An organization’s information systems refer to a set of interconnected modules that gather, develop, store up, and distribute information. This is for the reason of supporting an organization’s administrative team in making decisions, controlling, coordinating and analyzing. Improving the computer information system is not a choice in this technology-motivated age. It is an obligation. Organizations that use the latest information system to collect, incorporate, and calculate internal plus external information are achieving competitive benefit over other organizations (Rainer 50). With the development of communication networks and systems, there are almost no obstacles between the organization’s administration, customers, employees and suppliers. Management now caters much faster to a customer’s requirements and moans. Networked computing systems have

South Asia Region Essay Example for Free

South Asia Region Essay South Asia, which consists of the nations of Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka, is ethnically diverse, with more than 2,000 ethnic entities with populations ranging from hundreds of millions to small tribal groups. South Asia has been invaded and settled by many ethnic groups over the centuries including various Dravidian, Indo-Aryan and Iranian groups and amalgamation of Dravidian, Indo-Aryan and native societies has produced composite cultures with many common traditions and beliefs. But, the traditions of different ethnic groups in South Asia have diverged throughout earlier times, sometimes giving rise to strong local traditions such as the distinct South Indian culture. Other ethnic groups, successively streaming in later mainly from Central Asia and Iran, e.g. Sakas, Kushans, Huns etc. influenced pre-existing South Asian cultures. Among the last of these new arrivals were the Arabs followed by the Turks, the Pashtuns and the Moghuls. However, Arab influence remained relatively limited in comparison to that of the Turks, Pashtuns and Moghuls, who brought in much cultural influence and contributed to the birth of Urdu, a syncretic language of combined Indo-Persian heritage, which is widely spoken today. Ethnic Englishmen and other Britons are now practically absent after their two centuries long colonial presence, although they have left an imprint of western culture in the elite society. Languages See also: Languages of South Asia The largest spoken language in this region is now HindustÄ nÄ «, its speakers numbering almost 422 million;[75] the second largest spoken language is Bengali, with about 210 million speakers.[76] Urdu is also a major language spoken in the subcontinent, especially in Pakistan and India, and is similar linguistically to Hindi; Hindi and Urdu together make up HindustÄ nÄ «. Although Hindi is spoken in some states of India, many people are not aware of the fact that most of the Indians speak local languages and are not familiar with Hindi. Other languages of this region fall into a few major linguistic groups: the Dravidian languages and the Indo-Aryan languages, a sub-branch of the Indo-Iranian branch of the Indo-European languages. The other great sub-branch of Indo-Iranian, the Iranian languages, also have significant minority representation in South Asia, with Pashto and Balochi being widely spoken along the northwestern fringes of the region, in modern-day Pakistan. Many Tibeto-Burman ethnic groups, who are speakers of their language-group, are found in northeast India, Tibet, Nepal, and Bhutan. Other small groups, speaking Austro-Asiatic languages, are also present in South Asia. English is another language which dominates South Asia, especially as a medium of advanced education and government administration. Most of South Asia writes using various abugidas of BrÄ hmÄ « origin while languages such as Urdu, Pashto, and Sindhi use derivatives of the Perso-Arabic script. Not all languages in South Asia follow this strict dichotomy though. For example, Kashmiri is written in both the Perso-Arabic script and in the Devanagari script. The same can be said for Punjabi, which is written in both Shahmukhi and GurmukhÄ «. Dhivehi is written in a script called TÄ na that shows characteristics of both the Arabic alphabet and of an abugida. Religions Further information: Religion in Bangladesh, Religion in Bhutan, Religion in India, Religion in Nepal, Religion in Pakistan, and Religion in Sri Lanka Hindu priest saluting the sun in the Ganges, Varanasi, India   Jama Masjid, the main mosque in Delhi, India. About 64% of the South Asia population is Hindu, 33% is Muslim, 2% is Buddhist and 1% is Christians.[74] In South Asia Hinduism and Islam and in some of its countries Buddhism are the dominant religions. Other Indian religions and Christianity are practiced by significant number of people. Historically, fusion of Indo-Aryan Vedic religion with native South Asian non-Vedic Shramana traditions and other Dravidian and local tribal beliefs gave rise to the ancient religions of Hinduism and Jainism. As a consequence, these two religions share many similar cultural practices, festivals and traditions. Arabs brought the Abrahamic religion of Islam to South Asia, first in the present day Kerala, Sri Lanka and the Maldive Islands and later in Sindh, Balochistan and much of Punjab. Subsequently, Muslim Turks/Pashtuns/Moghuls furthered it not only among the Punjabi and Kashmiri people but also throughout the Indo-Gangetic plains and farther east, and deep south up to the Deccan.Afghanistan[1]Islam (99%), Hinduism, Sikhism and Christianity (1%) Bangladesh[77]Islam (89.5%), Hinduism (9.5%), Buddhism (0.7%), Christianity (0.3%) British Indian Ocean Territory[78]Christianity (45.55%), Hinduism (38.55%), Islam (9.25%), Others (6.65%) Bhutan[79]Buddhism (75%), Hinduism (25%) Burma[80]Theravada Buddhism (89%), Islam (4%), Christianity (Baptist and Roman Catholic) (4%), Animism (1%), Others (including Hinduism) (2%) India[79][81]Hinduism (80.5%), Islam (13.4%), Christianity (2.3%), Sikhism (1.9%), Buddhism (0.8%), Jainism (0.4%), Others (0.6%) Maldives[82]Sunni Islam (100%) (One must be a Sunni Muslim to be a citizen on the Maldives[83][84]) Nepal[85]Hinduism (80.6%), Buddhism (10.7%), Islam (4.2%), Kirat (1.5%) Pakistan[86]Islam (96.28%), Hinduism (1.85%), Christianity (1.59%), Ahmaddiyya (0.22%) Sri Lanka[87]Theravada Buddhism (70.19%), Hinduism (12.61%), ), Islam (9.71%), Christianity ( 7.45%). Economy Further information: Economy of Bangladesh, Economy of India, Economy of Nepal, Economy of Pakistan, and Economy of Sri Lanka South Asia is the poorest region on the earth after Sub-Saharan Africa. Three South Asian nations — Bangladesh, Bhutan and Nepal — are characterized as least developed country. Poverty is commonly spread within this region. According to the poverty data of World Bank, more than 40% of the population in the region lived on less than the International Poverty Line of $1.25 per day in 2005, compared to 50% of the population in Sub-Saharan Africa.[88] Sri Lanka has the highest GDP per capita in the region, while Afghanistan has the lowest. India is the largest economy in the region (US$ 1.90 trillion) and makes up almost 82% of the South Asian economy; it is the worlds 11th largest in nominal terms and 3rd largest by purchasing power adjusted exchange rates. Pakistan has the next largest economy and the 5th highest GDP per capita in the region,[89] followed by Bangladesh. According to a World Bank report in 2007, South Asia is the least integrated region in the world; trade between South Asian states is only 2% of the regions combined GDP, compared to 20% in East Asia. The Economist has blamed this on Indian neglect of its neighbors.[90] [edit] Governance India[91] and Pakistan[92][93] are the dominant political powers in the region. India is by far the largest country in the area covering around three-fourths the land area of the subcontinent.[94] It also has the largest population of around three times the combined population of the 6 other countries in the subcontinent.[95] India is also the most populous democracy in the world[96] and is a nuclear power. The second largest country in the subcontinent in terms of area and population is Pakistan and has traditionally maintained the balance of power in the region due to its strategic relationships with nearby Arab states[97] and neighboring China.[98] Pakistan is the 6th[99] most populous country in the world and is also a nuclear power. Bangladesh is the third largest populous country in the region. The single largest contributor to UN peacekeeping operations is Pakistan.[100] Diplomacy among the countries of South Asia has been mainly driven by populist politics, with the center stage taken by India-Pakistan conflict ever since their independence in 1947, and then the creation of Bangladesh under tense circumstances in 1971. While the elite rulers of Pakistan chose the USA led bloc during the cold war era, India formed the Non-Aligned Movement. The political situation in Sri Lanka has been dominated by an increasingly assertive Sinhalese nationalism, and the emergence of a Tamil separatist movement under LTTE, which was suppressed recently. Burmas politics is dominated by a military Junta, which has sidelined the democratic forces led by Aung San Suu Kyi. [edit] Health and nutrition There are 421 million MPI-poor people in eight Indian states alone Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh and West Bengal while there are 410 million in the 26 poorest African countries combined.[101] Roughly 42% of Indian children under age 5 suffer from malnutrition.[102] According to the World Bank, 70% of the South Asian population and about 75% of South Asias poor live in rural areas and most rely on agriculture for their livelihood.[103] According to the Global Hunger Index, South Asia has one of the highest child malnutrition rates in the world.[104] In a latest report published by UNICEF in 2008 on global hunger shows that the actual number of child deaths was around 2.1 million.[105] As of 2008 India is ranked 66th on the global hunger index.[citation needed] The 2006 report stated that the low status of women in South Asian countries and their lack of nutritional knowledge are important determinants of high prevalence of underweight children in the region. Corruption and the lack of initiative on the part of the government has been one of the major problems associated with nutrition in India. Illiteracy in villages has been found to be one of the major issues that need more government attention. The report mentioned that, although there has been a reduction in malnutrition due to the Green Revolution in South Asia, there is concern that South Asia has inadequate feeding and caring practices for young children.[106]

Functionalist Views Essay Example for Free

Functionalist Views Essay Functionalism is a predominant perspective.The functionalists see education as a miniature society, where the individual develops a sense of commitment to the social group; it is a place to learn rules where the individual learns to conform to societies cultural norms and values. The functionalist perspectives of Emile Durkheim are, he believed that the major function of education was the transmission of societies norms and values. This would allow an advanced division of labour, which contributes to the economy. He believed in the process known as socialisation, where cultural norms condition an individual, allowing entry to modern society. The economy greatly relies on educational conditioning, and it is essential that educational achievement is well balanced in the meritoractic society, for role allocation to occur. The individual must be suitably-fitted for his or her post. From a functionalist perspective schools sieve individuals in accordance to their ability for example by tiered examinations. This process in which educational failure is seen positively, aids role allocation. Parsons backed Durkheim s theory. He believed that education fulfils the function of secondary socialisation, thus allowing role allocation to occur. He firmly believed that role allocation was necessary for the functioning of society and the economy. His perspectives encouraged meritocracy, where the individual is rewarded on the basis of merit or ability and not thier background. There are various conflict theories, which give different views regarding the role of education. For example the Marxist perspectives of education argue that the education system imposes values of a higher class origin. In addition, achievement is based merely on social background and therefore makes failure inevitable. They belive that the education system serves capitalism and say that functionalists only look at the positives of the education system. Bowles and Gintis believed that the hidden curriculum benefits only the employer in a capitalist society, whereas a functionalist perspective would argue that without socialisation in educa tion, the individual would not recognise the norms and values of modern society. They believed that there is a strong relationship between capitalism and the educational system. The correspondence theory of Bowles and Gintis illustrates school as entry into a world of exploitive work, where the individual learns to believe in meritocracy. In contrast to a functionalist perspective, Giroux believed that the educational system is a site of ideological struggle, where the enforcement of class differences by aiding the middle class and neglecting the working class from achieving are obvious. Marxists believed that functionalism was to blame for the failure of the educational system, and because individuals are made to conform, they mostly oppose values emposed by schools. The enforcement therefore encourages a counter school culture. A functionalist would argue that bad behaviour, is exactly why individuals need to reform to the cultural norms of a modern day society if they are to succeed at all. Marxist and Functionalist perspectives of the role of education in modern Britain are evidently very different. Functionalism seems to be the main consensus perspective. Analysis of Functionalist views conveys the positive contribution made by education to the social system. Whereas the Marxist theories argue that the education system imposes dominant values of the middle class and neglects the working class. Marxists perspectives also believe that a disproportional amount of lower class individuals will continue to higher education as a result of ideological factors such as class and race. Marxists believed that the myth of meritocracy made the individual feel responsible for his or her own failure in education as opposed to the functionalist factors such as role allocation and the hidden curriculum which are clearly to blame for the inevitable failure of the individual. A Marxists perspective is probably more relevant to my own experience. I have experienced pressure from peer groups from higher social backgrounds of my own, and feel that without dress sense and money we are all able to achieve to similar standards, despite allowances sometimes made for richer more fortunate individuals.

Mycobacterium Marinum Treatment Literature Review

Mycobacterium Marinum Treatment Literature Review Abstract Background Mycobacterium marinum is an atypical mycobacterium that can be found in water environment. It is the agent of a characteristic skin disease known also as fish tank granuloma. In some occasions it can spread as a nodular lymphangitis, extend to deep structures as well as in exceptional cases disseminate systemicaly . The infection is adquired after contact with fish or contaminated water mainly from aquaria or swimming pools. Although the real incidence is understimate, it is a uncommon infection that needs high clinical suspicion to be diagnosed. As a consequence, delay in the diagnosis is common. Mycobacterium marinum is intrinsically a multidrug resistant mycobacterium.There is no clear consesus in the management of this infection. Usually it is managed either with monotherapy or with combination of antibiotics plus surgery in selected cases. Methods Retrospective study of cases of fish tank granuloma collected from 2000 to 2009 in the dermatology surgery of The Hospital of Tropical Diseases (HTD) of the University College London Hospitals. Systematic review of the literature with the terms Mycobacterium marinum and fish tank granuloma from 1999 to 2009. Results From the HTD dermatology surgery were collected 7 cases. Identification of M. marinum was possible only in 5. The response to treatment was good at least in 5 of them. In the literature review there were reported a total of 516 cases. From those 133 could be analyzed as individual cases. Identification was possible in 89.5% of the cases. Cured was reported in 82% of the cases. Conclusion The key of the diagnosis is to collect accurately the history of exposure. Histology, although no pathognomonic, will rise the suspicion if granuloma formation are found and will facilitate the differential diagnosis. Identification is done after culture with classical biochemical tests. Molecular biology techniques have the advantage of accelerate the procedure. There is not enough evidence to propose any specific treatment. Currently, recommendations are based in experts opinions. A prospective, randomized controlled clinical trial would be valuable to propose a base evident treatment. Contents Pages Introduction M. marinum is an environmental atypical mycobacterium ubiquitous in fresh, salt, and brackish water. It is known that infects temperate and tropical species of fish of at least 150 species, including ornamental fish. But also affects frogs, eels, oysters, aquatic mammals, toads and snakes [2, 11]. It cause tuberculosis-like disease in fish, its natural host [129]. The infection in fish has an average incubation period of 3 months. It affects viscera and produce anorexia with emaciation, skin defects, distension of the abdomen, being cause of sudden death [11, 12, 66]. In 1904, Alexander described for first time lesions in a cod fish that were associated with acid fast bacilli. But it was Aronson in 1926 that isolated the bacteria from tubercles of fish that died in an aquarium of Philadelphia. He described the bacilli as acid fast, chromogenic, pleomorphic and growing best at 18 º-20 ºC. Aronson suggested the name of Mycobacterium marinum [130]. M. marinum is as well the causative agent of the human disease called fish tank granuloma, also known as swimming pool granuloma or fish fancier ´s finger syndrome. In 1951 Norden and Linell reported for the first time the human disease in a swimming pool outbreak in ÃÆ'–rebro, Sweden. They described the lesions as chronic papulous ulcerations, usually located in the elbows. The pathogen was isolated from the walls of that swimming pool as well as from the lesions of the patients. They called the pathogen isolated Mycobacterium balnei [131]. It was not until 1959 when Bojalil demonstrated that M. marinum and M. balnei were in fact, the same mycobacterium [132]. M. marinum is the most frequent cause of skin infection among the environmental mycobacterium that affects humans [86, 133]. Nowadays the frequency of human infections is mainly sporadic. But in the past, outbreaks related with swimming pools were not uncommon [134]. As an example, one of the biggest epidemics was in Glenwood springs pool, Colorado in 1956 with 262 cases reported [135]. That was before chlorination became a common practice. Chlorination makes water safer. As was seen recently in Bologna, were water from swimming pools were free of M. marinum. But still could be isolated in 4.5% of the samples from the shower floor of the same [136]. The real global incidence of the disease is not know because the number of cases are underreported, due probably to the difficulties in the diagnosis [94]. It is world wide distributed but with a tendency to aggregate geographically [137]. Like in Chesapeake bay, Maryland, where there is an incidence of 4 cases per 100000 population per year [138]. Meanwhile in California was estimated in 0.27 cases per 100000 adults [139]. Or in Satowan, Micronesia, with an estimated prevalence of 10% of the population [115]. Apparently the global annual incidence remains small and stable [140]. Even though an increase number of reported cases has been noticed in The United States, going from an average of 40 cases per year in the 80s to an average of 198 cases per year in the 90s [141]. What seems clearer is that differing from other atypical mycobacteria the prevalence of M. marinum has not increased with the HIV epidemic [140]. Opposite to humans, the incidence in fish is increasing in hatchery fish, probably due to the high population density of fish. Transmission is possible fish to fish and between fish and amphibians. In addition it has been proposed transmission through eggs and through practice of feeding fish with fish carcasses [140]. There are 2 groups or clusters of M. marinum with different pathogenicity. Cluster I is characterized by producing acute disease and death in fish and also for affecting humans. On the contrary, cluster II only affects fish producing the classical chronic disease with granuloma formation [9]. This is also supported by a study done in Israel were it was seen that only certain strains of M. marinum affected humans. They also demonstrate that in Israel strains affecting humans came from ornamental fish and not from local fish for consumption [5]. The mode of transmission to humans is mainly waterborne and fish borne. Person to person transmission has not been documented [137]. However, It has been described indirect transmission via fomites in at least 3 cases. Two very small children and one infant who acquired the infection after bathing in containers that were previously used to clean the family fish tanks of tropical fish [27, 40, 142]. As other environmental mycobacterium, M. marinum has commonly low pathogenicity. For this reason in normal conditions only affects disrupted skin [8]. The main risk factor to contract the infection consists in having lesions or abrasions in the skin with exposure to non chlorinated water or marine animals infected [140]. The most frequently nowadays is the exposure to private aquaria. But some times the source of exposure is unknown. As a consequence, after the description of cases following injuries with plants, it has been suggested the possibility that could be other reservoirs different from water and fish. Although at the present moment this possibility has not been demonstrated [30, 43]. The incubation period is usually 3 to 4 weeks [135]. Following, the most common manifestation is a cutaneous lesion at the site of inoculation. It initiates as a solitary nodule or pustule that eventually evolutes to an ulcer , abscess or verrucous plaque [143]. It affects more frequently the extremities, probably because the pathogen grows better at low temperatures [144]. The severity of the disease depends, among other factors, on the number of microorganisms inoculated [134] In 20% of the cases the cutaneous lesions spread along ascending lymphatic vessels. This is called sporotrichoid spread or nodular lymphangitis [143]. As a result of direct extension invasion of deep structures as tendons, articulations and bones occurs in 29% of the cases [144]. Systemic dissemination is unusual but has been described in immunocompromised patients [140]. Spontaneous resolution , usually with scaring , has been documented from months after the infection up to 2 years [133, 135]. The diagnosis is based on the history of exposure and risk factors along with the characteristic clinical features. It is supported with histopathology, culture and bacteriological identification that in some cases require molecular biology techniques [94, 120]. The fact is that the diagnosis is not easy and in most of the cases is either delayed or remain being presumptive based in the history and response to treatment. The objective of the treatment is to increase the speed of resolution and prevent progression of the disease [1]. With this purpose different combinations of antibiotics plus the support, in selected cases, of surgery are the common practices in the treatment of this infection. Although the election of the drugs still depends of the preference of individual authors and is not based on controlled evidence [143]. Aims and Objectives The overall aim of the project is to determine the current state of evidence for the diagnosis and treatment of M. marinum infection. Being the specific objective to review the literature and the series of HTD cases with the purpose of suggest appropriate diagnosis and case management of Mycobacterium marinum infection. Material and Methods Cases with diagnosis of fish tank granuloma were review. The cases were diagnosed and treated from 2000 to 2009 in the dermatology surgery of The Hospital of Tropical Diseases of the University College London Hospitals. There were included patients with either culture positive for M. marinum or clinical diagnosis plus response to appropriate treatment. The files of those patients were reviewed and data were collected in a questioner that included: anthropological data, past medical and drug history, risk factors and exposure, description and location of the lesions, spread or deep extension of the infection, incubation period , delay in diagnosis, diagnosis, treatment and evolution (see questioner in annex). Additional information considered relevant was as well collected. A literature review in Medline and Cochrane databases was done. The review included the combination of the following terms: Mycobacterium marinum or fish tank granuloma. It was limited to papers from 1999 to July 2009, English and Spanish literature and humans. The papers obtained in the search were divided in 3 categories. First, case reports in which it was possible to collect data from individual cases. Information of those papers was collected in the questionnaire previously mentioned. Second, case series of 14 or more cases in which data from individual cases was not reported. And finally, a miscellaneous category of papers that were considered relevant for the diagnosis and treatment of this infection. The information gathered in the questioners was computerized in Microsoft Excel 2007. No statistical analysis was done in view of the cases were publish not with this purpose. As a consequence probably important reporting bias would invalidate any statistical outcome. Simple description of the results was done. Results Cases of The Hospital of Tropical Diseases From 2000 to July 2009 there were collected 7 cases with diagnosis of Mycobacterium marinum infection. The 7 cases included 6 males and 1 female and their ages ranged form 31 to 65 years. All the cases admitted to have had contact with an aquarium. In two cases the exposure was occupational. One of them worked in the London Zoo being responsible of the management of the aquaria. The second was a cook in a restaurant that store crustacean in an aquarium. All the cases presented nodular lesions located in one of the upper limbs, six of them with sporotrichoid spread and one with a solitary nodule (see photos is annex). One patient that was taking oral prednisolone due to severe atopic eczema presented with tenosynovitis of the left hand, sporotrichoid spread and palpable regional lymphonodes. The rest of the patients were not immunosuppressed. Biopsy of the lesions was performed in all the cases. However AFB were found just in one case. Whereas cultures were positive in 5 cases for M. marinum. In the other two cases the diagnosis was done based on history of exposure, clinical characteristics and positive response to treatment. Different combinations of antibiotics were used with no clear advantage of any regimen in particular. In 4 patients it was need to change the regiment. The reasons were drug intolerance in one case and lack of improvement in the rest. There was also one case that initially was improving with a regimen of rifampicin plus minocycline. But after simplification of the regiment to clarithromycin monotherapy presented worsening of the lesions. This case was eventually controlled switching to minocycline plus ethambutol. There was one patient who presented a relapse after one year of the previous infection. Finally it was cured with 6 months of rifampicin plus clarithromycin. Susceptibility test was done in 3 cases. It was detected resistance to trimethoprim-sulfamethoxazole and rifampicin in one case and susceptibility to clarithromycin, ethambutol and doxycycline in 3 cases. The average time of duration of the treatment was 6 months with a range of 2 to 9 months. Surgery was not required in any patient. The final outcome was good in 5 patients being the other 2 lost of follow up (see table 1). Case No Age(y) /Sex Medical history Drug history Exposure Location Clinical characteristics Histology AFB results Culture Treatment Duration (months) Evolution 1 9/M No Aquarium Upper limb Multiple nodules sporotrichoid spread Granulomatous inflammation AFB + 1-RIF+DOX 2-RIF+EMB+DOX 3-RIF+EMB+CLR 7 Cured 2 61/F Psoriasis Chronic paronychia Aquarium Upper limb 3 nodules Sporotrichoid spread AFB + 1-MIN 2 Improving Lost of follow up 3 64/M No Aquarium Upper limb Multiple nodules Sporotrichoid spread Noncaseating granuloma 1-EMB+TET 2-RIF+EMB+INH 9 Relapse after 1year 3(*) 65/M Fish tank granuloma Aquarium Upper limb Multiple nodules Sporotrichoid spread 1-RIF+CLR 6 Cured 4 59/M Severe atopic eczema Systemic steroids Aquarium Upper limb Multiple nodules Sporotrichoid spread Tenosynovitis AFB + 1-DOX 2-RIF+EMB 3-RIF+EMB+CLR 4-ERI+MIN ? Lost of follow up 5 44/M No Aquarium Upper limb 5 nodules Purulent discharge Sporotrichoid spread Necrotizing granulomatous inflammation AFB- + 1-RIF+MIN 2-CLR 3-MIN+EMB 3.5 Cured 6 31/M No Aquaria (London Zoo) Finger Solitary nodule AFB + 1-CLR+EMB 4 Cured 7 49/M No Aquarium (Restaurant) Upper limb 5 nodules Sporotrichoid spread + 1-RIF+EMB 5 Cured (*) Notice that case number 3 is repeated. It belongs to the same patient that the one above but one year later. The patient presented a relapse after one year of being cured. Results from the literature review From 1999 to July 20009 there were found 233 results in Medline database and zero In Cochran Library. From those, 127 were considered relevant and consequently analysed in this review. From the 127 papers reviewed, 108 contained case reports and the 19 remaining were a miscellaneous of reviews or original articles covering issues related with diagnosis and treatment. No clinical trials or randomized control trials were found. In those years the literature reported a total of 516 cases of M. marinum infection. From those cases reported only 133 could be analyzed as individual cases. The rest of cases were reported as series of cases (See figure 1). The number of cases reported per year since 1999 up to July 2009 have been variable with a minimum of 6 cases per year in 2004 to a maximum of 88 cases in 2000. No clear tendency to increase neither decrease has been notice (see Figure 2). The majority of the cases have been reported in Europe, North America and South East Asia. No cases have been reported in Africa and only one case in South America (see Figure 3). Results from papers that could be analyzed as individual cases The reports included 82 men and 51 women. The average age was 46.7 years with a minimum of 18 months and a maximum of 87 years (see Figure 4). 70% of the patients had no relevant past medical history. 9% of the patients were immunosuppressed: 5 patients had HIV infection, 4 were recipients of solid organ transplant, 1 patient had a myelodisplastic syndrome, 1 had Non-Hodking Lymphoma and 1 had Chronic Lymphocytic Leukaemia. Among other relevant pathologies were reported 12 diabetic patients, 11 with rheumatic diseases and finally 5 that were suffering from other problems as: asthma, bullous pemphigoid, myasthenia gravis, Cronh ´s disease and sarcoidosis. The majority of the patients were not taking any relevant drug. However, 20 of them were on systemic steroids, 12 had received steroids as local injection, 10 took methotrexate and 9 TNF-blockers. The most frequent exposure referred was the contact with an aquarium usually of tropical fish, it was reported in 51% of the cases. It was followed in 26 cases (20%) by other kind of contact with fish mainly referred as contact while cooking or cleaning fish. Finally 16 cases (14%) had other kind of contact with water environment. That included mostly fishermen or recreational sailors. Opposite to papers from the 60s, only in 2 patients referred contact with swimming pools. In 15 cases (11%) the source of exposure was not recall or reflected in the papers. Injury related with plants was reported in 3 cases. In one case the exposure was a bucket. The bucket was used to bath a child of 18 months after being used to put fish from an aquarium. As a result the child got infected [40]. History of trauma with skin barrier impairment was referred in 46 cases (71%) of the patients. Among those, 18 cases (39%) recall direct injury with either fin fish, fish hook or crab bite. Occupational exposure was reported in 20 cases (15%). The most frequent occupational risk was to be cook and have injuries while cleaning fish. Another common job of high risk was to work in a pet shop, with the duty of cleaning aquaria. Finally fishermen are evidently in direct contact with water and fish and prone to suffer injures with fish hooks. The incubation period was documented only in 30 patients. It went from 1 day up to 4 months with and average of 48.9 days. The cases that presented an incubation period less than two weeks had in common to have suffered penetrating injuries with fish (figure 5). The upper limbs were affected in 120 case (90.2%), being the fingers the most frequent location. The lower limbs were affected in 11 cases (8.3%). The face in 7 cases (5.3%) and that included delicate locations as nostrils, eyelid and cornea. Finally, cutaneous dissemination was reported in 7 cases (5.3%). Sporotrichoid spread was found in 53 cases (39.8%). Lymphonodes affectation was recorded in only in 7 cases (5.3%) of the cases. The lesions were described as nodules in 63 cases (7%), plaques in 23 (17.35%), papules in 13 (9.8%) and ulcers in 22 (16.5%). There was purulent discharge in 32 cases (24.1%), as well as swelling and tenderness in 37 (27.8%) and 42 (72.4%) cases respectively. Involvement of deep structures was referred in 45 cases (33.8%) of the cases being the most frequent tenosynovitis with 34 cases (75.6%), followed by arthritis with 12 (26.7%) and osteomyelitis with 6 (13.3%). Systemic dissemination with documented bacteraemia was reported in 3 cases. The 3 of them were males from 66 to 87 years. In 2 cases the patients were on systemic steroids, due to myasthenia gravis[103] in one case and polymyalgia rheumatica[62] in the other. Sadly the third case that initially was not taking drugs, after being misdiagnosed as rheumatoid arthritis was put on systemic steroids, infliximab (TFN blocker) and methotrexate [59]. From the patients with invasive disease, including involvement of deep structures or systemic dissemination, 21 (46.6%9 were taken some kind of immunosuppressive drug. Meanwhile only 13 (15.5%) of the rest of the patients were taken them (see figure 6). Other interesting characteristic of the patients with invasive disease was that 15 (33.3%) of them referred direct fish injury. Only 3 (3.4%) of the rest had this exposure (see figure 7). Patients that for any reason were taken immunosuppressive drugs presented different characteristics from the rest of the patients. More than half of them presented invasive disease compared with only 20% of the rest (see table 2). Patients taking immunosuppressive drugs (*) Patients no taking any drugs Number of patients 36 91 Average age (years) 53.2 44.9 Female % 14 / 38.9% 36 / 39.6 % Sporotrichoid spread 13 / 36.1% 39 / 42.8% Involvement deep structures 21 / 58.3% 19 / 20.8% Systemic dissemination 3 / 8.3% 0 AFB positive 19 / 52.7% 33 / 36.3% Culture 33 / 91.6% 75 / 82.4% Bad evolution 2 / 5.5% 3 / 3.3% (*)Immunosuppressive drugs including: TNF-Blockers, systemic steroids, local injectable steroids, methotrexate and azathioprine. The time of evolution until the patients presented for consultation was as short as 4 days and as long as 18 years with an average of 8.6 months. The time until the diagnosis was finally done was only reflected in 17 patients. However the delay went from 21 days to 2 years with an average of 6.3 months. Tuberculosis skin test was only done in 19 patients. From those 86.4% were positive. Biopsy of the lesions was done in 120 cases (90.2%). Aspirate was reported only in 19 cases (1 4.3%). Histology characteristics suggestive of mycobacterial infection with granuloma formation were found in 45.5% of the biopsies. However, only 21% of those were described as caseating granulomas. Other frequent finding reported was mix infiltrates with chronic and acute inflammatory cells. In some cases a wrong diagnosis was done due to confusion with rheumatoid nodules, Sweetà ¢Ã¢â€š ¬Ã¢â€ž ¢s syndrome, foreign body granuloma or interstitial granuloma annulare (See table 3). Table 3: Histology Findings Histology description Number of patients Non caseating granuloma 19 Caseating granuloma 12 Granuloma( type not specified) 26 Infiltrates of chronic and acute inflammatory cells (lymphocytes , neutrophils, histiocytes) 18 Granulation tissue 6 Abscess formation 9 Necrotizing folliculitis 1 Focal dermal necrosis 3 Fibrinoid degeneration 1 Necrotizing paniculitis 2 Cystic degeneration 1 Pseudoepitheliomatous hyperplasia 4 Acute suppurative paniculitis 1 Fibrinous exudates 3 Lichenoid inflammation 1 Acanthosis in epidermis 2 Necrotic Corneal Stroma 1 Dermal fibrosis 2 à ¢Ã¢â€š ¬Ã‚ ¢ Pseudocarcinomatous hyperplasia of follicles à ¢Ã¢â€š ¬Ã‚ ¢ Nodular and perifollicular infiltrate of neutrophils and histiocytes à ¢Ã¢â€š ¬Ã‚ ¢ Dermal fibrosis à ¢Ã¢â€š ¬Ã‚ ¢ Collections of neutrophils within follicles 1 patient with lesions of 18 years evolution Confusion with other pathologies Rheumatoid Arthritis ( rheumatoid nodule) 2 Sweet ´s syndrome 2 Foreign body granuloma 2 Interstitial gra nuloma annulare 2 In the samples collected AFB was found in 41.7%, was negative in 34.6% and was not reported in 23.6%. In total identification of M. marinum was possible in 119 cases (89.5%). Culture was positive in 114 cases (85.7%). The time until the cultures grew went from 8 to 56 days, with an average of 23.3 days. Identification with PCR was done in 19 cases (14.2%). The imaging techniques were useful to diagnose extension of the infection. Radiographies were used in 25 cases (18.7%) to rule out bone involvement. Magnetic resonance imaging was used in 16 cases (12%) resulting in the diagnosis of tenosynovitis, abscess, join effusions or osteomyelitis. About the treatment, 126 patients were treated with antibiotics; in the rest of the cases the management is not mentioned. Surgery was need in 38 patients (84.4%) with affectation of deep structures and in 21 patients (25%)with cutaneous lesions. Monotherapy was used in 54 cases (42.8%), bitherapy in 38 cases (29.4%), triple therapy in 20 cases (15%) and combination of 4 or more drugs in 5 cases (4%). Finally combinations of drugs that included classical tuberculosis treatment were used in 10 cases (8.7%). In 41 patients the regimen of drugs needed to be change, either for non effectiveness or non tolerance. The regiment was change one time in 29 cases (21.8%), two times in 10 cases (7.5%), and up to 3 times in 2 patients (1.5%). The drug more frequently used as monotherapy was clarithromycin, followed by minocycline, doxycycline, ciprofloxacin and trimethoprim-sulfamethoxazole. The combinations of drugs more frequently used were rifampicin + ethambutol followed by clarithromycin + rifampicin and clarithromycin + ethambutol. (Effectiveness of the different regimens depending of the extension of the disease can be seen in table 4) Susceptibility test were reported in 34 patients. Rifampicin was susceptible in 86.4% of the test, ethambutol in 91.3%, clarithromycin in 95% and minocycline in 62.5%. Isoniazid was resistant in 100% of the tests done and streptomycin in 66.6% (see table 5). The average time of duration of antibiotic treatment was 5.4 months, with a range of 12 days to 15 months. After completion of the treatment the final evolution of 109 patients (81.9%) was reported as good outcome or cured. Only in 8 patients (6%) the evolution was reported as bad outcome. No mention about the evolution was done in the rest of cases. Among 12 patients in which long follow up was reported, only one patient presented recurrence of the infection after 3 months course of doxycycline. (Characteristics of the cases with bad outcome are resumed in table 6. Table 4:: Antibiotic Combinations Used Depending On The Extension of The Disease Patients with only cutaneous lesions Patients with Invasive disease Number of patients Effectiveness Number of patients Effectiveness Monotherapy 38 52.5% 16 75% CLR 8 75% 5 100% MIN 10 70% 1 100% DOX 8 50% 1 100% CIP 4 25% 2 50% CTX 2 100% 3 33.3% AZI 3 0% 0 AMK 1 0% 0 ERI 0 1 0% LEV 0 1 0% MOX 1 0% 0 OFL 1 0% 2 50% Combinations of 2 drugs 26 92% 11 83.3% CLR + EMB 6 100% 2 100% CLR + CIP 1 100% 0 CLR + MIN 1 100% 0 CLR + RIF 5 80% 0 CLR +CTX 1 100% 0 RIF + EMB 9 100% 5 60% RIF + CTX 0 1 100% RIF + INH 0 1 100% CIP +DOX 1 100% 0 CIP + EIR 1 0% 0 DOX +CTX 0 2 100% CIP + EMB 1 100% 0 Combinations of 3 drugs 13 72.7% 7 66.6% CLR + EMB + CIP 0 1 0% CLR + EMB + RIF 2 100% 5 100% CLR + EMB +RFB 0 1 0% CLR +CTX + CIP 1 0% 0 EMB + AZI + MIN 1 0% 0 RIF + CLR + AMK 1 100% 0 RIF + INH + CLR 1 0% 0 RIF + EMB + CTX 5 100% 0 RIF + EMB + DOX 1 0% 0 RIF + EMB + MOX 1 0% 0 Combinations of > than 3 drugs 2 100% 3 33.3% CIP+RIF + EMB + CLR + RFB + AMK 0 1 100% CLR + DOX + RIF + EMB 0 1 0% RIF + EMB + CLR + AMK + IMP 0 1 0% RIF + EMB + AZ I+ CTX 1 100% 0 RIF + EMB + CLR + CIP 1 100% 0 Combinations with TB treatment 1 100% 9 55.5% INH + RIF + EMB + CLR 1 100% 1 0% INH + RIF + EMB 0 3 100% INH + RIF + EMB + PZA 0 4 50% INH + RIF + EMB + PZA + CLR 0 1 0% TABLE 5: PATTERN OF SUSCEPTIBILITY Drug Number of patients Susceptible Resistant Indeterminate Isoniazid 9 9 Rifampicin 22 19 3 Ethambutol 23 21 2 Pyrazinamide 1 1 Streptomycin 6 1 4 1 Rifabutin 2 2 Azithromycin 4 1 3 Clarithromycin 20 19 1 Minocycline 8 5 1 2 Doxycycline 6 6 Tetracycline 2 1 1 Trimethoprim-sulfamethoxazole 6 5 1 Ciprofloxacin 11 6 1 Levofloxacin 1 1 Moxifloxacin 4 4 Gatifloxacin 1 1 Amikacin 9 9 Linezolid 1 1 Imipenem 2 2 Erythromycin 2 1 1 Cefotaxime 2 1 1 Kanamycin 3 3 Ethionamide 3 3 Ansamycin 1 1 The table reflects in how many patients each drug was tested and in how many it resulted as susceptible, resistant or indeterminate. TABLE 6: CHARACTERISTICS OF CASES WITH BAD OR POOR OUTCOME References Age Sex Past medical history Type of infection Treatment Duration treatment (months) Evolution [25] 67/M DM Cutaneous disseminated RIF+EMB+CLR+CIP 3.7 Deceased Secondary bacterial infection [26] 50/M No Tenosynovitis RIF+EMB Synovectomy 3 Dysfunctional index finger [46] 62/F No Tenosynovitis CLR 4 debridements 6 Amputation index finger [46] 26/M No Tenosynovitis DOX+CTX 4 debridements 3.5 Persistent infection Need of grafting [73] 56/M No Tenosynovitis Local gentamicin Synovectomy 3 drainages ? Deformity [83] 47/M HIV infection Osteomyelitis 1-INH+RIF+EMB+PZA 2-Avobe + Fluoroquinolone 3-RFB+EMB+CIP 4-RFB+CIP ? Amputation Knee [88] 60/F NHL Systemic steroids Cutaneous disseminated 1-Ofloxacine 2-RIF+EMB+LEV+CLR 3-Above+STR+IG 4-CTX+MOX ? Continue with signs of active infection [103] 81/M Myasthenia gravis Systemic steroids Cutaneous and systemic dissemination 1-CIP 2-Hyperthermia 3-DOX intravenous 5 Deceased Bone marrow infected by M.marinum Results from papers that contain series of 14 or more cases There were 14 papers that contained series of cases with no available information of individual cases. As a consequence, individual cases could not be analyzed separately. There were 2 papers that reported the same series of cases in different years, the cases were counted just once. The principal characteristics of the papers are described in the table 7. There were 363 cases reported, 68% were males with an average of 44.3 years. In most of the cases the past medical history was not relevant; only 4 cases of HIV infection were reported. The most frequent exposure was to own an aquarium in 134 cases (37%). There was other kind of contact with fish in 37 cases (10%), swimming pool contact in 7 cases (2%) and other kind of contact with water in 58 cases (16%). In the rest of cases exposure was not mention. Finally occupational exposure was referred in 68 cases (19%). The incubation period was not reported. The upper limbs were affected in 245 cases (67%), the lower limbs in 78 cases (21%), the face in 3 cases (0.8%) and there was cutaneous dissemination in 10 cases (3%). Sporotrichoid spread was reported in 46 cases (12%). The lesions were described as plaques in 92 cases (25%) and nodules in 54 cases (15%). Deep structures were affected in 45 cases (12%): 41 tenosynovitis (91%), 8 arthritis (18%) and 3 osteomyelitis (6%). There were no cases of systemic dissemination described in any of the series. The average in the delay until the diagnosis was done was 3.8 months. The drugs more commonly used as monotherapy were doxycycline, minocycline, trimethoprim-sulfamethoxazole and clarithromycin. The combinations more prescribed were rifampicin plus ethambutol, rifampicin plus clarithromycin and clarithromycin plus ethambutol. The effectiveness of the treatments were not frequently reported. Consequently is not possible to point the advantage of any concrete regimen (see table 8). The average duration of the treatment was 5 months. Surgery was reported in 73 cases (20%). The evolution was good in 225 cases (62%), poor in 15 cases (4%) and not mention in the rest. There were 5 papers that contained series of cases of atypical mycobacterial infecti

Windows 98 :: essays research papers fc

Microsoft Windows 98 Microsoft Windows 98 is an operating system and its predecessor was Windows 95. An operating system is the interface between you and the computer, which helps manage files and makes using your personal computer simple and easy. While this release was not as big as Windows 95, Windows 98 contains significant updates, fixes, and support for new peripherals. Features like improved protection and better support make Windows 98 a quality upgrade. A new type of file system called FAT32 is used to take advantage of hard disk space, while Windows 95 supported PnP (plug and play). Windows 98 built on that technology and detects devices even better then 95, which will greatly increase the ease of hardware installation. Bundled in the installation of Windows 98 you will get some new software such as Internet Explorer 4.0 and Microsoft Outlook. These additions help Windows 98 take a big step forward. For familiarity and ease of use, Windows 98 has been modeled to look more like Windows NT. A cop y of Windows 98 can be obtained for around $100.00 - $200.00. An upgrade is also available, but you must already have Windows 3.1 or Windows 95 to use the upgrade CD, which costs between $80.00 and $100.00. System Requirements   Ã‚  Ã‚  Ã‚  Ã‚  Before installing Microsoft Windows 98, it is important that the user make sure you meet the minimum system requirements. For better performance, you will want to exceed the minimum requirements. The system requirements for the installation of Windows 98 are as follows: System Component  Ã‚  Ã‚  Ã‚  Ã‚  What You Need DOS version  Ã‚  Ã‚  Ã‚  Ã‚  Minimum: DOS 3.31. Recommended: DOS 5.0 or higher. DOS 4.0 was so buggy that you're really taking a chance installing Windows 98 over it. Processor  Ã‚  Ã‚  Ã‚  Ã‚  Minimum: 66 MHz 486DX2 Recommended: Pentium, Pentium MMX, or Pentium II. However, Pentium Pro systems do not run Windows 98 noticeably faster than other Pentiums running at the same clock speed. The Pentium Pros are optimized for pure 32-bit code (such as you find in Windows NT), and Windows 98 contains enough 16-bit code to prevent any significant speed increases. Memory  Ã‚  Ã‚  Ã‚  Ã‚  Minimum: 16MB. Recommended: Windows 98 runs much better with 24MB of RAM. For best results, I recommend at least 32MB, with 64MB being the bottom line for the truly impatient. Hard disk free space  Ã‚  Ã‚  Ã‚  Ã‚  Minimum: The minimum amount of space required by Windows 98 Setup is 225MB. Recommended: A full install of Windows 98 could use up as much as 400MB of hard disk space. (See the following Note box.) Setup may also require another 45-50MB for the backup copies of your system files, and Windows 98 will need 20MB or 30MB for its dynamic swap file.

Confucianism Essay -- Religion Religious Essays Papers

Confucianism   Ã‚  Ã‚  Ã‚  Ã‚  Confucianism is a system of thought based on the teachings of a Chinese man named Kung Fuzi. Which is latinaized as Confucius, he lived from 551 to 479 b.c.e. Confucius claimed that he was not original and neither were his teachings, but believed himself to be a â€Å"creative transmitter of wisdom from the past†. He created a moral code on based on ethics, humanity and love. Confucius philosophies emphasize the ideals of order and harmony. With the idea that people should live in harmony both with each other and with nature. To achieve this, Confucius created a system of human relationships and good government. Government to Confucius was the highest profession. He believed that if one had a good government everyone would be happy. In addition, Confucius esteemed education in high regards believing that through it, one could reach the high standard of a gentleman..   Ã‚  Ã‚  Ã‚  Ã‚  For a religion Confucianism is very different from any other. Due to the fact that the Chinese see religion as a form of education. The purpose of Confucianism was mainly to instill moral values in a person. There is no organized church or structure, no priests, no sects, and no creed for any follow. There is no worshipping or personal relationship with god but did recognize heaven as a force of human concern. Confucius did believe that men should direct their own destiny. Confucius taught that harmony begins in the family, which was a minuet of society. In which the man of...

Conflict, Climax, Resolution of Hawthornes Young Goodman Brown Essay

Conflict, Climax, Resolution of â€Å"Young Goodman Brown†Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚        Ã‚   Hugo McPherson in â€Å"Hawthorne’s Use of Mythology† makes a statement regarding the nature of the conflict in the works of Hawthorne:    Everything he has to say is related, finally, to ‘that inward sphere.’ For the heart is the meeting-place of all the forces – spiritual and physical, light and dark, that compete for dominance in man’s nature. †¦Those who read him as a Christian moralist recognize instantly an opposition between Head and Heart, reason and passion which is related not only to Puritan theology but to the Neo-Classical view of man†¦.(68-69)    Nathaniel Hawthorne’s â€Å"Young Goodman Brown† is, in the estimation of various literary critics, an example of various types of conflicts. This essay will examine them and also the climax and resolution of this short story.    Edmund Fuller and B. Jo Kinnick in â€Å"Stories Derived from New England Living† state that   â€Å"’Young Goodman Brown’ uses the background of witchcraft to explore uncertainties of belief that trouble a man’s heart and mind† (31). The conflict between pride and humility is the direction that Clarice Swisher in â€Å"Nathaniel Hawthorne: a Biography† tends: Hawthorne himself was preoccupied with the problems of evil, the nature of sin, the conflict between pride and humility† (13). There is little doubt about the pride of the protagonist as he scolds his wife for not fully trusting him: "’My love and my Faith,’ replied young Goodman Brown, ‘of all nights in the year, this one night must I tarry away from thee. My journey, as thou callest it, forth and back again, must needs be done 'twixt now and sunrise. What, my sweet, pretty wife, dost thou doubt me already, and we but three mo... ...W. B. â€Å"The Return into Time: Hawthorne.† In Hawthorne – A Collection of Critical Essays, edited by A.N. Kaul. Englewood Cliffs, NJ: Prentice-Hall, Inc., 1966.    Martin, Terence. Nathaniel Hawthorne. New York: Twayne Publishers Inc., 1965.    McPherson, Hugo. â€Å"Hawthorne’s Use of Mythology.† In Readings on Nathaniel Hawthorne, edited by Clarice Swisher. San Diego, CA: Greenhaven Press, 1996.    Swisher, Clarice. â€Å"Nathaniel Hawthorne: a Biography.† In Readings on Nathaniel Hawthorne, edited by Clarice Swisher. San Diego, CA: Greenhaven Press, 1996.    Wagenknecht, Edward. Nathaniel Hawthorne – The Man, His Tales and Romances. New York: Continuum Publishing Co., 1989.    Williams, Stanley T. â€Å"Hawthorne’s Puritan Mind.† In Readings on Nathaniel Hawthorne, edited by Clarice Swisher. San Diego, CA: Greenhaven Press, 1996.          Conflict, Climax, Resolution of Hawthorne's Young Goodman Brown Essay Conflict, Climax, Resolution of â€Å"Young Goodman Brown†Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚        Ã‚   Hugo McPherson in â€Å"Hawthorne’s Use of Mythology† makes a statement regarding the nature of the conflict in the works of Hawthorne:    Everything he has to say is related, finally, to ‘that inward sphere.’ For the heart is the meeting-place of all the forces – spiritual and physical, light and dark, that compete for dominance in man’s nature. †¦Those who read him as a Christian moralist recognize instantly an opposition between Head and Heart, reason and passion which is related not only to Puritan theology but to the Neo-Classical view of man†¦.(68-69)    Nathaniel Hawthorne’s â€Å"Young Goodman Brown† is, in the estimation of various literary critics, an example of various types of conflicts. This essay will examine them and also the climax and resolution of this short story.    Edmund Fuller and B. Jo Kinnick in â€Å"Stories Derived from New England Living† state that   â€Å"’Young Goodman Brown’ uses the background of witchcraft to explore uncertainties of belief that trouble a man’s heart and mind† (31). The conflict between pride and humility is the direction that Clarice Swisher in â€Å"Nathaniel Hawthorne: a Biography† tends: Hawthorne himself was preoccupied with the problems of evil, the nature of sin, the conflict between pride and humility† (13). There is little doubt about the pride of the protagonist as he scolds his wife for not fully trusting him: "’My love and my Faith,’ replied young Goodman Brown, ‘of all nights in the year, this one night must I tarry away from thee. My journey, as thou callest it, forth and back again, must needs be done 'twixt now and sunrise. What, my sweet, pretty wife, dost thou doubt me already, and we but three mo... ...W. B. â€Å"The Return into Time: Hawthorne.† In Hawthorne – A Collection of Critical Essays, edited by A.N. Kaul. Englewood Cliffs, NJ: Prentice-Hall, Inc., 1966.    Martin, Terence. Nathaniel Hawthorne. New York: Twayne Publishers Inc., 1965.    McPherson, Hugo. â€Å"Hawthorne’s Use of Mythology.† In Readings on Nathaniel Hawthorne, edited by Clarice Swisher. San Diego, CA: Greenhaven Press, 1996.    Swisher, Clarice. â€Å"Nathaniel Hawthorne: a Biography.† In Readings on Nathaniel Hawthorne, edited by Clarice Swisher. San Diego, CA: Greenhaven Press, 1996.    Wagenknecht, Edward. Nathaniel Hawthorne – The Man, His Tales and Romances. New York: Continuum Publishing Co., 1989.    Williams, Stanley T. â€Å"Hawthorne’s Puritan Mind.† In Readings on Nathaniel Hawthorne, edited by Clarice Swisher. San Diego, CA: Greenhaven Press, 1996.