Analysis on the McLaren Group

Executive Summary There are market entry barriers for new entrants in the car market such as McLaren. The report shows that the industry has grown over the years to become one of the most competitive becoming a struggle for new entrant. The entrants face numerous challenges before they dominate or even penetrate the car market.Advertising We will write a custom report sample on Analysis on the McLaren Group specifically for you for only $16.05 $11/page Learn More The already existing companies in the car market are trying to develop new measures and strategies that will allow them to remain relevant in the market amidst economic slow growth and a decline in demand. These include diversification and investment in other areas to reduce risks. McLaren has been able to overcome most of the entry barriers to become a successful company despite the competiveness of the industry. Introduction The automotive industry has both good and tough times, which result t o times of growth and decline. The industry is highly competitive which poses a great challenge for new entrants and existing companies. Most of the entry barriers present in the mass car market is relevant to McLaren though they do not indicate a negative impact on the McLaren Group, which continues to establish new companies. The major challenges for new entrants include enormous upfront costs, high competition and marketing of the new brands. The market is not well-exploited owing to the challenges that face existing and new companies. It is beyond doubt that McLaren has been able to overcome the various market entry barriers present in the mass car market as evident from its dominance and high returns. Competition is a relevant market entry barrier for the company, which has been keen on identifying strategic groups that have similar business models and similar strategies in the car market. This is important in identifying its direct competitors and the basis on which they compe te and identify any opportunities. The company has been able to keep up with its main competitors such as Ferrari owing to sufficient market research, which identifies major areas of improvement and competitive advantage. For example, the company is making cars that are faster, comfortable and economical in an effort to compete with its main rivals. It uses product development articulated by Ansoff’s Matrix to introduce new products into existing market to boost competition against its rivals (Kerr 2005, p. 156). The enormous amount of capital to start a car company is another relevant market entry barrier for McLaren. The company was able to amass huge capital from its initial investors such as Bruce McLaren, shareholders and external financial assistance from banks and other financial institutions.Advertising Looking for report on business economics? Let's see if we can help you! Get your first paper with 15% OFF Learn More It was able to establish other segm ents such as Absolute Taste from the huge revenues generated by the racing team. The company, which started as a racing team, has been able to divert its returns to fund and establish new segments such as McLaren Applied Technologies and McLaren Electronic Systems that are a source of huge revenues (Young 2005, p. 58). Marketing investment is a market entry barrier for McLaren owing to the expense and challenges of marketing a new brand in an existing market. McLaren was able to prioritize its expenditure budget by dedicating a significant amount of money to extensive advertisement to create awareness of the brand. It was able to advertise itself further by becoming one of the most successful Formula 1 team by recording grand prix victories thus creating more awareness of the brand. The company teams up with other companies such as Mercedes to boost its image and have a competitive advantage (Gray Gray 2000, p. 32). The company was able to develop its own manufacturing line and pro duction center to carter for its needs for limited capacity of part suppliers. This ensures that it has access to spare parts that it needs since it has its own manufacturing and production line. Other relevant entry barriers include government regulations and patent protection laws that may prevent use of certain innovations. McLarens develops its products in accordance to the government regulations regarding safety and fuel efficiency through the development of cars that meet such standards. This is possible owing to use of high and competent employees that are conversant with the regulations. McLaren Group is not only involved in Formula 1 or sports cars but it is involved in other businesses off the track. It is able to generate around  £ 33 million in annual profits from its companies, which constitute its portfolio (www.worksmart.org.uk). It has shown a high level of diversification with the establishment of six separate companies in different markets, which constitute its p ortfolio. According to the Ansoff’s matrix, McLaren embraces diversification by developing new products and offer them to new markets (Kerr 2005, p. 159). The company’s diversification is a departure from its initial existing product and market involvement, which is Formula 1 racing. There are six different companies in the portfolio including McLaren racing, McLaren marketing, McLaren Electronic Systems, McLaren Automotive, McLaren Applied Technologies and Absolute taste.Advertising We will write a custom report sample on Analysis on the McLaren Group specifically for you for only $16.05 $11/page Learn More The companies within the Group’s portfolio increase its value through increased returns and market share. The Group has a clear foresight by establishing a portfolio of companies that produce related products and others that produce non-related products. It is able to increase its market value while spreading out the risk and sa ves costs by utilizing its resources. The companies within the portfolio enjoy self-governance though there is the overall management, which looks at the management at the Group level. The Group integrates all companies into its management and uses similar development and management strategies (Sadler 2003, p. 14). McLaren racing is a successful team in the grand prix motor racing with major victories since its establishment in 1966. The McLaren Formula 1 team is the backbone of McLaren Company, which brings in huge revenues. McLaren Automotive is a state of art automotive production line, which is responsible for the production of the company’s vehicles. McLaren Electronic system is the company, which is responsible for the supply of electronic control unit to the Formula 1 team. It also produces electronic systems for teams and championships especially in North America and Europe. McLaren Applied Technologies uses Informational Technology and Data management expertise to he lp Formula 1 team improve on their performance. In addition, the Group has opened a new  £40 million production center to boost its production. Absolute Taste offers both catering and hospitality services to guests in Formula 1 race and specializes in events and party hosting around the world. The Group’s portfolio consists of McLaren Marketing, which is responsible for advertisement and creating awareness of the brand. It is important to note that McLaren diversifies but builds and holds on some products such as racing to increase market share or maintain current market share according to Boston and Ansoff Matrix (Levine Tyson 1990, p. 16). There exists either a direct or an indirect relationship between the companies under the McLaren group of companies. The portfolio stretches well with companies indulging in different markets such as food and hospitality though the major companies indulge in the car market and related services. The presence of six companies is a clear indication of the high levels of diversification within the McLaren Group (Gray Gray 2000, p. 68).Advertising Looking for report on business economics? Let's see if we can help you! Get your first paper with 15% OFF Learn More There is a high relatedness rate among the companies, which support each other financially and logistically. The Group concentrates on product development and differentiation to develop companies in its portfolio that provide related products and services. This allows the company to save on huge upfront costs and divert expenditure to develop its own companies. This allows the companies in the portfolio to integrate its activities and offer support.. There are several reasons why McLarens developed the portfolio to include other companies. The main reason is to boost its dominance and achieve synergy by developing related companies and products (Sadler 2003, p. 56). In addition, the company stretched out the portfolio to reduce risks related to economic uncertainties. The Group aims at achieving strategic fit with complementary marketing, manufacturing and production efforts. The Group’s most companies are directly related where the companies are able offer support to other c ompanies. McLaren group is able to save huge amounts of money, which it would use by seeking external assistance from other companies. For example, McLaren Electronic systems supply the team members with high-end electronics that aid them in their competition. The diversification allows the company to have a competitive advantage over its competitors by developing new companies and new products. The group benefits by heavily investing in technology and electronics, which is essential in the car market, and racing industry. The portfolio is possible owing to the Group’s already existing resources and high levels of brand loyalty. The Group finds it important to invest in other non-related markets such as Absolute Taste to spread its risks and try to mitigate the effects of financial, political and other risks. The company, which is not directly related to the car market is source of revenue and increases the Groups asset base. In addition, McLaren has a safe level of diversifi cation as articulated by the portfolio’s composition or configuration. The companies in the portfolio have a high level of relatedness where it is possible to share assets and resources. The companies are able to share resources such as technology and the Group’s assets to carry out their business endeavors (Levine Tyson 1990, p. 39). Most of the companies relate in terms of products and services meaning that there is lots of cooperation between them.However, each company is in an effort to secure its own assets and develop its resources. There is a positive correlation between portfolio of assets and the creation of value for the company. McLaren group is able to add value by diversifying its businesses making it effective in resource and capital utilization. It increases value by investing its returns on other businesses that have the capacity to grow and contribute to the value of the group. There is a large value of bundle assets and business compared to independe nt unit owing to huge asset base, which can attract more financial assistance. McLaren also enjoys large market share and asset dominance. McLaren has a unique approach to diversification, which is partially different from the historic perspective on corporate diversification. Over the years, there has been a change in the approach of diversification owing to new research and change in strategies. The trends in corporate diversification have been changing due to the change in the economy and continued research on the concepts. The Group realizes the dynamics in the approach to diversification and the numerous benefits of applying different diversification concepts. In early 1950’s, companies were diversifying mainly due to management competencies through portfolio planning techniques (Goold Luchs 1993, p. 10). This has been changing as companies concentrate on the effect of diversification on performance. The companies have a deep thinking and understanding of diversificatio n and its effect on the company’s performance. They are concentrating more on performance measurement after diversification to determine the benefits of diversification. In the late 1980’s companies were using value based planning concepts to scrutinize diversification and make concrete decisions. Goold Luchs (1993, p. 20) says that in the early 1990’s companies were diversifying through the establishment of companies that produce related products. This move supported good performance where companies improved on returns and profitability. Later in the years, companies started using core competencies and dominant logics as a driving factor for diversification. It is important to note that some approaches of the concept of diversification come and go. Companies are going back in time to incorporate strategies of diversification with the current strategies in an effort to come up with the best diversification approach. It is important to note that companies such a s McLaren incorporate more than one diversification approach to maximize its benefits. Consequently, companies are concentrating on performance measurement to determine whether the diversification strategy is beneficial. Although research indicates that diversification leads to higher performance, companies appreciate that unrelated extensively diversified companies have a poor performance. In the early year, companies were not carrying out performance measurement on diversification since they believed to have high performance. The approach of diversification by McLaren reflects on the historical perspective on corporate diversification where there was focus on the role of corporate headquarters. In the early years, companies did focus on corporate headquarters to determine their role in case of diversification. This is evident in McLaren scenario where the corporate headquarters have a big role to play in diversification of the company and marketing of products (Reed 2010, p. 2). T he historical perspective on corporate diversification insists on sticking to the diversification strategy and executing the outlined strategy. There is a strong relationship between the historical approach of diversification and that of McLaren. This is because the company insists on performance measurement of the diversification process. Conclusion McLaren Group has proven to be one of the most successful companies in the highly competitive car market industry. This is evident from its growth over years and its continued dominance in the industry. It is able to overcome market entry barriers through different mechanisms that ensure its relevance and success in the industry. McLaren is one of the few companies that have been able to overcome market entry challenges and increase its portfolio of companies as a means of market penetration. The diversification of its business operations are one of the major contributors of its success. McLaren has seen the benefits of relating diversi fication and performance as proven by Goold and Luchs (1993, p. 45). It has a review of past diversification concepts to establish the best and outstanding diversification approach. McLaren has a high level of diversification with a Group portfolio consisting of six companies. This is one of the main reasons for the continued growth and success of the Group where it plans to invest  £750 million over 5 years (Reed 2010, p. 2). References Goold, M Luchs, K 1993, ‘Why diversify? Four decades of management thinking’, Academy of Management Executive, vol. 7 no. 3, pp.7- 25. Gray, A Gray, T 2000, Studies in Economics and Business: Marketing, Heinemann Publishers, New York. Kerr, J 2005 ‘Diversification strategies and managerial rewards’, Academy of Management Journal, vol. 28 no. 6, pp. 155-179. Levine, I. Tyson, D 1990, Participation, productivity, and the firm’s environment, Brookings Institution, Washington, D.C. Reed, J 2010, ‘McLaren enter s sports car market’, Financial Times, vol. 2 no. 4, pp. 1-2. Sadler, P 2003, Strategic Management, Kogan Page Publishers, Washington. Young, E 2005, McLaren Memories: A Biography of Bruce McLaren Haynes, Oxford University Press, Oxford, UK. This report on Analysis on the McLaren Group was written and submitted by user Marvin B. to help you with your own studies. You are free to use it for research and reference purposes in order to write your own paper; however, you must cite it accordingly. You can donate your paper here.

Best Foot Forward

Best Foot Forward Best Foot Forward Best Foot Forward By Simon Kewin Someone who puts their best foot forward must, logically, have three or more feet. Although this is a very common phrase (the title of a 1943 Lucille Ball film, for example) it is, at least for humans, grammatically incorrect. Best is the superlative form of the adjective good and superlatives are used to refer to one item from a group of three or more. The comparative form of the adjective better in the case of good should be used to refer to one item from two. So, the phrase should be better foot forward if talking about a biped. Only a creature with three or more feet a centipede for example could actually put its best foot forward. The general point applies to all comparative and superlative adjectives. You cant be the fastest runner in a race of two, for example, only the faster. Here are some examples of this usage around the web: There are hopeful signs. On Wednesday he conceded he couldnt get the economy going again simply by blaming the Democrats, up to now his favorite response to the recession. And he said yesterday that he would run on my whole record, suggesting that he may put his best foot forward instead of merely stepping on his opponents. NY Times The Bears arrived in St. Louis without their best pass rusher - Pernell McPhee stayed home with a knee injury - and yet they left with a convincing TKO of a potent Rams offense. LA Times Want to improve your English in five minutes a day? Get a subscription and start receiving our writing tips and exercises daily! Keep learning! Browse the Expressions category, check our popular posts, or choose a related post below:Homograph ExamplesThe Writing ProcessThrew and Through

Protein and Amino Acid Essay Example | Topics and Well Written Essays - 500 words

Protein and Amino Acid - Essay Example A lack of amino acids in daily diet will have a greater impact on all cellular development, respiration, or renewal of cells would cease. In total there are only 22 amino acids that join together to form different proteins. In fact amino acid chains combine to form up to 55,000 different proteins, and each protein is used to produce the enzymes, neurotransmitters, and hormones that support normal growth and functioning of all organs, including the heart, brain, liver, intestine, kidneys, and sex organs (Vitaminstuff.com n. pag). Amino acids are categorized into two groups the essential amino acids that should be taken along with diet and non-essential amino acids that are produced by the body. The essential amino acids are isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine. Non-essential amino acids are those that the body can manufacture from an available source of nitrogen and a carbon skeleton. The nonessential amino acids are arginine, alanine, asparagine, aspartic acid, cysteine, glutamine, glutamic acid, glycine, proline, serine, and tyrosine (Vitamin Supplements Guide n. pag). The benefits of taking amino acids as dietary supplements are many these include muscle protein maintenance, proper immune function, affecting neuronal activities in the brain, tissue repair acceleration after burn or trauma, protecting liver from toxic agents, pain relief

Managing Operations Essay Example | Topics and Well Written Essays - 750 words

Managing Operations - Essay Example The paper will therefore analyze the production strategy the managers should choose based on the total cost minimization objective as well as summarizing the information about the aggregate plan to be shared with the supply chain partners. Production strategy based on the Total Cost Minimization The total cost minimization normally occurs at appoint when the marginal cost (MC) curve cuts the average total cost (ATC) curve at its minimum point. This therefore means that, at the minimum point, marginal cost (MC) should be equals to the Average Cost (AC). In most cases, the decision problems are usually molded as being a cost-minimization problem, and therefore, in every network, models usually have a minimization objective. The reasoning behind this is that, in particular, the decision situations never influences the income, hence minimizing costs will increase the opportunities of maximizing the profit (Shim & Siegel, 2002). The production manager should choose on pricing-based as a p roduction strategy to help in making decision based on the total cost minimization. When managers use price-based strategy, the products are usually planned according to cost-plus pricing, value-based pricing as well as target-return pricing. All these are set in such a way that the new product in the market has a competitive advantage over other similar products. Therefore, when there is no overtime for employees, managers have to make sure that the time spent by those employees is compensated for as opposed to when they work on normal hours (Media, 2010). Aggregate Plan The aggregate forecasts of the tank loads for several flavors should be shared to various supply chain partners. The forecast contains the intended tank load production every month from May through September. The company’s production capacity every month is also very important information for the suppliers. The company’s maximum tank loads production in a particular month is 60 tank loads, in May the forecast is 50 tank loads, in June it is 60, in July 70, in August 90, September 80 and finally October 70.There are several months where the forecasted production in a month exceeds the company’s ability these are the months of July, August September and October. Therefore this information on the extra tank loads that the company needs is very crucial supply chain partners. This is because from the information they will get to know of any extra tank loads that the company might require in a particular month and therefore their services might be required. This will give them a chance to offer the company their services in terms of producing the extra tank loads that they have forecasted and yet they are not in a position as a company to produce (Shim & Siegel, 2002). The other Very important information that the supply chains need is the amount of money that is set aside by the company as cost of subcontracting as well as overtime production by various supply chains. Subcontr acting and over production by the suppliers who are available is $1600 and $1800 per tank load. Therefore with this information any supply chain that intends to supply the extra trainloads can be in a position to set a price for their tank loads. They will ensure that they come up with prices that will give them a chance to be chosen as the preferred supplier for the extra tank loads. They also need to know the cost of holding tank loads in a month as well as backordering if made by the company. This will help them make a

Operation Management Eassy Essay Example | Topics and Well Written Essays - 2000 words

Operation Management Eassy - Essay Example (Chase, 2001, 5) Buffa discussed that 'OM had progressed from an entirely explanatory foundation through the Management Science/Operations Research (MS/OR) phase, and is currently in the course of finding itself as a practical field of organisation. Amoako-Gyampah, K., Meredith, J., 2004, 251), Many authors, since the beginning, advocated that OM should be an area of knowledge with a 'sense of purpose’, in terms of providing insight into problems of the real word, the ones engineers and managers face in their work. As Chase (2001) observed, when analysing the four journals that historically, at that time, had published most extensively with OM subjects - namely, AIIE Transactions, Decision Sciences, Management Sciences and the International Journal of Production Research - that the orientation (people or equipment) and emphases (from micro to macro) were heavily focused on equipment and micro analyses as, for instance, inventory control and scheduling. This picture was changed , as we will see in this literature review. 2.2 Areas of Operation Management As presented by Buffa, the first call for papers sketched out a list of topics that defined the Operation Management subjects. Since then, relevant studies as Miller and Graham, Voss, Amoako-Gyampah and Meredith, Pannirselvam et al. and Gupta, Verma and Victorino, among others, using different approaches, were carried out looking to identify the content, new topics and trends in the field, and also to establish new research agendas. Nowadays, the scope of the journals focused on OM is considerably broader. (Miller, J., and Graham, M., 2004, 548) Operation Management borrows theories from other areas and that 'this field has changed from its narrow occupation with strategic, disjointed topics toward more premeditated, incorporated and large-scale subjects. For instance, as an alternative of studies in the tactical, stand alone areas of 'Inventory' and 'Process Design’; researchers are now looking at the complete 'Supply Chain' and organisation-wide 'Flexibility', correspondingly (Anderson, 2008, 58). Decision Areas within Operation Management includes Design of products and services Quality Management Development and capacity plan Location strategy Layout strategy Human resources & employment design Supply chain management Inventory, material requirements, progression and JIT (Just-in-time) Intermediate and short-range scheduling Maintenance Description of Layout Strategy of Operation Management The arrangement of equipments, departments and work centers with special concentration on movement of work (consumers or materials) all over the system is called Layout of organization. Selecting an appropriate layout of an organisation requires significant investments of funds and hard work, which involves serious commitment. Appropriate layout of an organisation leaves considerable effect on cost and competence of various operations within the organisation. There are several types of layout, which are as follows. Fixed Position layout In Fixed Position layout manufactured goods and whole project remains motionless. However, employees, materials, and machinery move from their position according

Dengue Fever and Malaria in Thrombocytopenic Patients

Dengue Fever and Malaria in Thrombocytopenic Patients Frequency of co-existence of dengue fever and malaria in thrombocytopenic patients presented with acute febrile illness Dr. Shazia Yasir*, Dr. Muhammad Owais Rashid, Dr. Faisal Moin, Dr. Komal Owais ABSTRACT Introduction: Hepatitis c virus infection affects more than 170 million people worldwide. [1] About 80% of patients with acute infection will afterward develop chronic disease. [15] Interferon (IFN) alpha in combination with ribavirin (RBV) is the current standard care of treatment of chronic hepatitis C virus infection worldwide. Unfortunately, both drugs have significant hematological toxic effects (anemia, neutropenia and thrombocytopenia) Objectives: To determine the frequency of hematological side effects (anemia, neutropenia and thrombocytopenia) during combination therapy with interferon and ribavirin in chronic hepatitis C patients. Study Design: Cross-sectional, observational study. Place and Duration of Study: Department of Emergency Medicine, Ziauddin University Hospital, Karachi from Ten months from April 2013 to January 2014. Methodology: A total of 228 patients of chronic HCV, and meeting inclusion criteria were included from OPD of Ziauddin Hospital North Campus Karachi, Sarwar Zuberi Liver Centre and Hepatogastroenterology Section, SIUT. After taking informed consent, patients were given injection IFN 3 MIU subcutaneously thrice weekly and ribavirin 800 – 1200 mg/day, as per body weight, that was, those less than 50 kg will receive 800 mg/day, 50 – 75 kg was received 1000 mg/kg and more than 75 kg was received 1200 mg/day. Result: Overall mean age was 39.6 ( ±9.2) years with Male: Female = 2.2: 1. Hematological abnormalities was seen in 79 (37.3%) cases. Anemia was the most common type of hematological abnormalities developed in 41 (19.3%) cases followed by neutropenia in 33 (15.6%) and thrombocytopenia in 21 (9.9%) cases. Conclusion: Amongst the hematological disorders. Anemia and thrombocytopenia was the most common and least common respectively during the combination therapy of chronic hepatitis C. while neutropenia followed as second common and serious hematological disorder. Key words: HCV, anemia, neutropenia, thrombocytopenia, Interferon, ribavirin. _____________________________________________________________________________________________ INTRODUCTION Hepatitis C Virus (HCV) infection is a global health problem. The virus infects approximately 3% of the world population; placing approximately 170 million people at risk of developing HCV related chronic liver disease. [1] Currently, chronic hepatitis C infection is the most frequent indication for liver transplantation and accounts for estimated 8000 – 10000 deaths each year in the United States. [2] HCV infection is endemic in Pakistan [3] and is a considerable threat to our population. [4] The prevalence of HCV in Pakistan is reported to be 3.29% [3], 3.3% [4] and 3.69% [5] in different studies. Cure of chronic hepatitis C in the natural course is rare, and the rate of progression to cirrhosis and hepatocellular carcinoma is also significantly high. The eradication of hepatitis C virus during the chronic stage is, therefore, extremely important. [6] - Department of Emergency Medicine, Ziauddin University Hospital, North Campus, Karachi * Correspondence Email: [emailprotected] Treatment with pegylated interferon plus ribavirin has become the standard of care for patients infected with chronic hepatitis C. [7] However, standard interferon and ribavirin combination is still widely in use in Pakistan for chronic hepatitis C infection, because of its low cost. Unfortunately, both drugs (interferon and ribavirin) have significant hematological toxic effects (anemia, neutropenia and thrombocytopenia). [8,9,10] Anemia during combination therapy for chronic hepatitis C begins to develop almost immediately after therapy is initiated and becomes most pronounced after 4 to 6 weeks of treatment.8 Hemoglobin levels do not usually change after week 12 to the completion of treatment. [6] The values for incidence and severity of anemia during combination therapy for chronic hepatitis C are higher in Asian studies than in the non-Asian studies. In a study conducted in Taiwan, the mean decrease of hemoglobin was 3.9  ± 1.3 g/dL and 39% of the patients developed severe anemia (hemoglobin levels below 10 g/dL). [9] Treatment with interferon and ribavirin combination therapy is also associated with neutropenia that is more frequent with peg interferon as compared to standard interferon. [11] A study from the National Institutes of Health specifically examined neutropenia associated with combination therapy. The mean neutrophil count decreased by 34% during the 24 to 48 week course of therapy and the frequency of neutropenia was noted to be 63%. [12] Thrombocytopenia is another well known complication of antiviral therapy for chronic hepatitis C but has been infrequently associated with dose reduction or discontinuation. [11] During therapy with at least one dose of standard or pegylated interferon, platelet count decreased by nearly 28%. [13] Few studies have been conducted in Pakistan to assess the side effects of combination therapy in chronic hepatitis C. The frequency of anemia is reported to be 19.6% and of thrombocytopenia to be 13.7% in one study. [14] Another study stated that hematological side effects were noted in 92% of the patients. [10] No local study is available reporting the frequency of neutropenia during treatment for chronic hepatitis C. Hematological abnormalities are the most common indications for dose reduction in chronic hepatitis C therapy. Hematological abnormalities accounts for at least one dose reduction in approximately 25% of patients during therapy. Dose reductions or premature discontinuations results in significantly lower sustained virological response. [11] Because hematological side effects have implications on virological response, therefore, knowledge regarding frequency of these side effects is of utmost importance. As stated earlier, there are very few trials conducted in Pakistan that examined the hematological side effects of combination therapy and most of the data in this regard have come from western population. Pakistani population is different from western population in many ways, for example, the HCV genotype 1 infection is more common in west while genotype 3 infection in Pakistan. Moreover, host factors like different genetic makeup, difference in immune status and lower body mass inde x (resulting in lesser dose of ribavirin required during therapy) for Pakistani population may have implications on frequency of the hematological side effects of combination therapy. In addition, there is an enormous difference in the frequencies of side effects reported in different studies conducted at national level. Therefore, there is a need to add-to and strengthen the national literature. This study was designed to determine the frequency of the hematological side effects of combination therapy (interferon and ribavirin) in patients with chronic hepatitis C. METHODOLOGY The study was planned to be conducted on patients attending the out-patient department of Civil Hospital Karachi, Sarwer Zuberi Liver Centre and Hepatogastroenterology Section, Sindh Institute of Urology and Transplantation. Sample size ( n ) = 182 + 25% of 182 = 228* Proportion of thrombocytopenia ( P ) = 13.7%14 or 0.137 Confidence level (1 – ÃŽ ± ) = 0.05 Margin of error (d ) = 5% * A meta-analysis noted that during treatment for chronic hepatitis C approximately 25% of patients required at least one dose reduction for hematological abnormalities (anemia, neutropenia and thrombocytopenia) [11], therefore the sample size is augmented by 25% to cover the drop-outs because of dose reduction and drug discontinuation. Patients who will require dose reduction and drug discontinuation will be excluded from the study. The criteria for dose reduction and drug discontinuation are stated in data collection. Inclusion Criteria: Patients of either gender with chronic hepatitis C: Between the age of 18 and 50 years, Presence of anti – HCV, HCV – RNA and persistently raised ALT levels for more than 6 months (on at least two occasions). HCV Genotype 2 and 3; and Compensated liver disease (indicated by presence of all of the following: no history of ascites, bleeding esophageal varices or hepatic encephalopathy, serum albumin > 3 g/dL, serum bilirubin ≠¤ 2 mg/dl and prothrombin time Exclusion Criteria: Patients with: Decompensated liver disease HCV Genotype 1 (Infection with HCV Genotype 1 requires combination therapy for 48 weeks. The study is planned to be completed in 6 months.) Co-infection with HBV Pregnancy, Significant systemic illnesses other than liver disease (cardiovascular or renal dysfunction, chronic obstructive pulmonary disease, uncontrolled diabetes) Other contra-indications or precautions to combination therapy (history of epilepsy, depression or other psychiatric disorders, thyroid dysfunction, autoimmune hepatitis) Interferon/ribavirin therapy in the past Pre-treatment hemoglobin level less than 13 g/dL in males and less than 12 g/dL in females, pre-treatment neutrophil count less than 1500 cells/ÃŽ ¼L and platelet count less than 150,000 cells/ÃŽ ¼L Who require dose reduction or drug discontinuation during treatment. Criteria are mentioned in data collection. The source of the sample was the patients attending the out-patient department of Civil Hospital Karachi, Sarwar Zuberi Liver Centre and Hepatogastroenterology Section, Sindh Institute of Urology and Transplantation. Informed consent was taken from the patients who were meet the inclusion and exclusion criteria and the patients were given injection IFN 3 MIU subcutaneously thrice weekly and ribavirin 800 – 1200 mg/day, as per body weight, that was, those less than 50 kg will receive 800 mg/day, 50 – 75 kg was received 1000 mg/kg and more than 75 kg was received 1200 mg/day. The patients were evaluated at week 4, 12 and 24 and blood was drawn for complete blood counts. Dose of the interferon and/or ribavarin was reduced for any patient in whom hemoglobin level falls below 10 g/dL and/or neutrophil count drops below 750 cells/ÃŽ ¼L and/or platelet count falls below 50,000 cells/ÃŽ ¼L during the course of treatment. The therapy was discontinued in the patients in whom hemo globin level drops below 8.5 g/dL and/or neutrophil count falls below 500 cells/ÃŽ ¼L and/or platelet count falls below 30,000 cells/ÃŽ ¼L. These criteria for dose reduction and drug discontinuation were in accordance with the guidelines for treatment of chronic hepatitis C. The patients who were required dose reduction or drug discontinuation during the course of treatment was excluded from the study. The final outcome was measured at week 24, when the values for hemoglobin level, neutrophil count and platelet count was recorded for each patient in the performa given in annex 1. The patient was said to have developed anemia if the hemoglobin level falls below 13 g/dL in males and less than 12 g/dL in females, neutropenia if neutrophil count drops below 1500 cells/ÃŽ ¼L and thrombocytopenia if platelet count falls below 1,50,000 cells/ÃŽ ¼L. Confounding variables like age, gender and body weight were controlled by stratification at the time of analysis. The collected data was analyzed with the help of SPSS program version 19.0. Frequencies and percentages were computed for presentation of qualitative variables like gender and side effects (anemia, neutropenia and thrombocytopenia). Mean  ± Standard Deviation was computed for variables like age and body weight. Confounding variables like age, gender and body weight were controlled by stratification. RESULT A total of 228 patients with chronic hepatitis C were included in this study. Sixteen (7.02%) of the patients were excluded due to dose modification or discontinuation during the follow-up period. Due to anemia dose was reduced in 6 and discontinued in 4 cases, due to neutropenia dose was reduced in 3 and discontinued in 1 case and in thrombocytopenia dose was reduced in 2 cases. Mean ( ±SD) age of patients was 39.6 ( ±9.2) years with range = 18 – 50 years. Majority of cases 113 (53.3%) had age between 20 – 40 years. Figure-1 Gender distribution showed male preponderance (male: female = 2.2: 1), 145 (68.4%) were males and 67 (31.6%) were females. Figure-2 Seventy Nine (37.3%) of the patients developed significant hematological abnormalities during treatment with interferon and ribavirin. Figure-3 Anemia was the most common type of hematological abnormalities developed in 41 (19.3%) cases followed by neutropenia in 33 (15.6%) cases and thrombocytopenia in 21 (9.9%) cases. Figure-4 Proportions of hematological abnormalities were similar in both genders. Fifty five (37.9%) were male and 24 (35.8%) were female. Figure-5 Types of hematological abnormalities were also similar in both males and females, 29 (52.7%), 23 (41.8%) and 15 (27.3%) of males and 12 (50%), 10 (41.7%) and 6 (25%) of females developed anemia, neutropenia, and thrombocytopenia, respectively in male cases. Table-1 Mean ( ±SD) age of those patients who developed hematological side effects was 38.4 ( ±8.6) years with range = 19 – 50 years. Majority of cases 56 (62.2%) had age between 20 – 40 years. Figure-6 FIGURE-1 AGE DISTRIBUTION n = 228 Mean  ±SD = 39.6  ±9.2 years Range = 18 – 50 years FIGURE-2 GENDER DISTRIBUTION n = 228 Male: Female = 2.2: 1 FIGURE-3 OVERALL HEMATOLOGICAL SIDE EFFECTS (SE) n = 212 Keys: hematological side effects were evaluated in this study as: Anemia = hemoglobin level 10 13 g/dL in males and 10 12 g/dL in females. Neutropenia = Neutrophil count between 750 1500 cells/ÃŽ ¼L. Thrombocytopenia = Platelet count of between 50,000 – 1, 50,000 cells/ÃŽ ¼L. SE = Side Effects FIGURE-4 TYPES OF HEMATOLOGICAL SIDE EFFECTS (SE) n = 212 Multiple response exist Keys: Anemia = hemoglobin level 10 13 g/dL in males and 10 12 g/dL in females. Neutropenia = Neutrophil count between 1500 750 cells/ÃŽ ¼L. Thrombocytopenia = Platelet count of between 1,50,000 50000 cells/ÃŽ ¼L. SE = Side Effects FIGURE-5 OVERALL HEMATOLOGICAL SIDE EFFECTS (SE) IN GENDER n = 212 Table-1 TYPES OF HEMATOLOGICAL SIDE EFFECTS (SE) IN GENDER n = 212 Keys: Anemia = hemoglobin level 10 13 g/dL in males and 10 12 g/dL in females. Neutropenia = Neutrophil count between 750 1500 cells/ÃŽ ¼L. Thrombocytopenia = Platelet count of between 50,000 150000 cells/ÃŽ ¼L. FIGURE-6 OVERALL HEMATOLOGICAL SIDE EFFECTS (SE) IN AGE GROUPS n = 212 Mean  ±SD = 38.4  ±8.6 years Range = 19 – 50 years DISCUSSION The treatment of CHC is now well established with conventional interferon or pegylated interferon in combination with ribavirin. [61] However, one of the main drawbacks of this combination therapy is the development of side effects, which can result in suboptimal dosing or discontinuation of therapy. This can limit the likelihood of SVR, since one of the determinants of SVR is adequate dose and duration of therapy, as previously discussed in this supplement. Among the side effects of combination therapy, hematologic abnormalities such as anemia, neutropenia, and thrombocytopenia have been reported to result in dose reduction and discontinuation of therapy in up to 25% and 3% of patients, respectively. [11] The withdrawal rate increases with both the duration of treatment and use of combination therapy. [101] For example, therapy was stopped in 13–14% of patients treated with interferon mono therapy for 48 weeks [102] compared with 19–21% of patients receiving combination therapy for the same duration. The withdrawal rate for combination therapy was lower when therapy was administered for only 24 weeks (8%). [103] Mean ( ±SD) age of patients was 39.6 ( ±9.2) years with range = 18 – 50 years. In this study seventy Nine, 37.3% of the patients developed significant hematological abnormalities during treatment with interferon and ribavirin and Sixteen (7.02%) of the patients were excluded due to drug modification or discontinuation during the follow-up period. A study from USA reported 38.2% of the cases developed hematological side effects during the combination therapy, a figure is similar to what is seen in this study.104 Another study conducted in Pakistan reported 92% mild to moderate hematological side effect during the combination therapy. [10] In this study anemia was the most common type of hematological abnormality seen in 19.3% of cases followed by neutropenia in 15.6% and thrombocytopenia in 9.9% cases. Study from USA reported 20.6%, 22.1%, and 8.1% developed neutropenia, anemia, and thrombocytopenia, respectively. [104] In another study from Pakistan, mild to modest anemia was noted in 70 % of the patients. [10] Anemia is caused both by interferon due to myeloseupression and ribivirin causing hemolysis. [24, 25] In same study mild to moderate neutropenia was reported in 64% of cases and thrombocytopenia in 61% of patients. [10] neutropenia is one of the expected side effects of combination therapy but the risk of the serious infection is very low even with severe neutropenia. [12] Similarly in clinically practice thrombocytopenia does not pose significant problem. [11] In conclusion hematologic abnormalities are common during combination antiviral therapy for chronic hepatitis C. Although dose reduction or discontinuation is tool of overcome these side effects, they can adversely affect the efficacy of combination antiviral therapy. This is especially true in the cases of ribavirin induced anemia. Recent evidence has led to increasing recognition that optimal dosing of ribavirin is a crucial determinant of viral clearance. Preliminary data suggest that hematopoietic growth factors may be useful for managing the hematologic side effects of combination therapy (especially anemia). CONCLUSION The frequency of hematological abnormalities during the treatment of chronic hepatitis C (HCV) in this study was comparable to those seen in certain other studies. Anemia was the most common and thrombocytopenia was the least common hematological side effect noted. The number of patients excluded from the study because of dose modification or drug discontinuation was also greatest due to anemia and least due to thrombocytopenia ACKNOWLEDGEMENT We would like to acknowledge faculty of Ziauddin Hospital, North Campus for helping us during the study, staff for helping in data collection and all others who have given their input. SOURCE OF FUNDINGS We would like to thank HighQ pharma for financially aiding the research and authors for their contribution. CONFLICT OF INTEREST There is no conflict of interest in any term regarding the article from any authors. REFERENCE Dengue Fever and Malaria in Thrombocytopenic Patients Dengue Fever and Malaria in Thrombocytopenic Patients Frequency of co-existence of dengue fever and malaria in thrombocytopenic patients presented with acute febrile illness Dr. Shazia Yasir (PG Emergency Medicine)*, Dr. Owais , Dr. Faisal Moin ABSTRACT Introduction: Both dengue fever and malaria can present with thrombocytopenia. Thrombocytopenia is a consistent finding in dengue fever and is regarded as a strong predictor of dengue fever. Thrombocytopenia is also considered criterion of disease severity, bad prognostic factor and its presence is associated with increase probability of malaria Objectives: To determine frequency of co-existence of dengue fever and malaria in thrombocytopenic patients presented with acute febrile illness in tertiary care hospital Study Design: Cross-sectional, observational study. Place and Duration of Study: Department of Emergency Medicine, Ziauddin University Hospital, Karachi from Ten months from April 2013 to January 2014. Methodology: A total of 159 patients meeting inclusion criteria were included in this study. 5ml of blood by venupuncture in EDTA anti-coagulant for platelet count and preparing thick and thin films and 2 ml of blood in plain bottle for detection of dengue specific IgM was collected from all patients. Thick films are used to identify malarial parasites and thin films to identify specie. Dengue fever was diagnosed on positive dengue IgM. Co-existence was labeled as positive if malarial parasites and dengue IgM found to be present at the same time. This diffusion susceptibility test was use to determine susceptibility of bacterial agents to antibiotics. Data was analyzed by descriptive statistics using SPSS software version 19. Result: Overall mean ( ±SD) age was 38.3 ( ±7.9) years, with Male to female ratio was 1.1: 1. Co-infections (Dengue and Malaria) were diagnosed in 5 (5.6%) of cases. From 5 cases, 3 (60%) were male and 2 (40%) were female. Mean ( ±SD) age of 5 positive cases of co-infection was 37.8 ( ±8.3) years. Conclusion: Concurrent infections were found 5.6% in this study. Although this percentage is slightly low; special attention should be given to the possibility of co-infection with malaria and dengue. Key words: Dengue fever, Malaria, Immunoglobulin-M (IgM), febrile illness, Thrombocytopenia _____________________________________________________________________________________________ INTRODUCTION Dengue Virus is becoming an increasing health problem. Over 99% cases of viral hemorrhagic fever reported worldwide are due to dengue hemorrhagic fever (DHF). [1] Dengue fever is cause by dengue viruses (DENVs) which are members of Flaviviridae family. [2] It has been estimated that 2.5 billion people live in areas which are at risk of epidemic transmission and over 50 million of DENV infections occur globally each year [3,4]. Since we are living in region where malaria is endemic and is considered as the most common cause of fever and in general practice empirical anti-malarial therapy is common, it is important to distinguish the two conditions due to clinical similarities and unexpected progress of dengue fever (DF) to DHF and dengue shock syndrome (DSS). [5] - Department of Emergency Medicine, Ziauddin University Hospital, North Campus, Karachi * Correspondence Email: [emailprotected] Both dengue fever and malaria can present with thrombocytopenia. Thrombocytopenia is a consistent finding in dengue fever and is regarded as a strong predictor of dengue fever. [6] Thrombocytopenia is also considered criterion of disease severity, bad prognostic factor and its presence is associated with increase probability of malaria [7, 8] In a local study Ali et.al showed that Out of 11 patients diagnosed as having dengue fever on serology 9 (81.8%) also had co-existence of malaria and thrombocytopenia was present in 90% of such patients. [5] Out of 11 DENV positive patients three patients died and first DENV positive patients who died was prescribed anti-malarial by general practitioner in outdoor. [5] On autopsy plasmodium falciparum rings were found in blood and DENV IgM was detected in serum samples [5] Due to clinical similarities in two conditions and possibility of extensive mosquito exposure, high co-existence of both conditions cannot be excluded. [5] This study aims to determine frequency of co-existing dengue fever and malaria in thrombocytopenic patients presenting with acute febrile illness so that magnitude of the condition could be assessed. The findings could be used to plan that all patients with acute febrile illness with thrombocytopenia must be screened for dengue fever without delay. METHODOLOGY This study was carried out at the department of emergency medicine, Ziauddin University Hospital, Karachi, Pakistan. Patients of either gender with more than 12 years of age presenting to Ziauddin Hospital Karachi with acute febrile illness and found to have thrombocytopenia were included in the study while patients known to have disease causing thrombocytopenia e.g. systemic lupus erythematous, idiopathic thrombocytopenic purpura and patients with other causes of acute febrile illness such as pneumonia, meningitis, enteric fever etc. diagnosed on blood culture, chest X-ray sputum C/S, urine D/R were excluded from the study. A total of 159 patient’s fulfilling inclusion criteria were included in the study. 5ml of blood by venupuncture in EDTA anti-coagulant for platelet count and preparing thick and thin films and 2 ml of blood in plain bottle for detection of dengue specific IgM was collected from all patients. Thick films are used to identify malarial parasites and thin films to identify specie. Dengue fever was diagnosed on positive dengue IgM. To minimize bias all specimen was sent to single central laboratory of the hospital. A proforma especially designed for the study was used to documents findings such as paients age, gender, name, malaria parasite, dengue IgM by the researcher. Co-existence was labeled as positive if malarial parasites and dengue IgM found to be present at the same time. Data was entered in computer and analyzed by SPSS version 19.0 frequency and percentages were calculated for categorical variables such as gender, co-existing dengue fever and malaria. Mean standard deviation was calculated for numerical variables like age. Stratification was done in terms of age and gender to see the effect of that on outcome. RESULT During the study, a total of 159 cases with thrombocytopenia of age > 12 years were included. From 159 cases, 82 (51.6%) were male and 77 (48.4%) were female. (Figure-1) Mean ( ±SD) age of 159 cases was 38.3 ( ±7.9) years with range = 15 – 53 years. Majority 66 (41.5%) of cases had age between 30 – 44 years. (Figure-2) Out of 159 thrombocytopenic cases presented with acute febrile illness, malaria was diagnosed in 55 (34.6%) cases. (Figure-3) Dengue fever was diagnosed on positive dengue IgM. Out of 159 cases, 34 (21.4%) of cases were diagnosed as dengue. (Figure-4) Co-infections (Dengue and Malaria) were diagnosed in 5 (5.6%) cases. (Figure-5) Out of 5 positive cases of co-infection, 3 (60%) were male and 2 (40%) were female. Mean ( ±SD) age of 5 positive cases of co-infection was 37.8 ( ±8.3) years with range = 15 – 52 years. Majority 3 (60%) of cases had age between 30 – 44 years. (Figure-6) DISCUSSION Despite a wide overlap between malaria and dengue endemic areas, published reports of co-infections are scarce in the literature. Malaria and dengue must be suspected in febrile patients living in or returning from areas endemic for these infections. The confirmation of malaria is rapid, and after malaria is confirmed, dengue is usually ruled out without screening for it. Two methods can confirm dengue: dengue-specific IgM sero-conversion or detection of dengue virus particles during the acute phase (day 0 to day 4 after onset of fever) by RT-PCR, which is faster and more specific. In published case reports, [9 – 12] the diagnosis of dengue infection is usually made based on positive dengue IgM; however, this cannot confirm recent dengue, because IgM can persist for months and cross-react with other arboviruses. [13] If RT-PCR requires a specific laboratory and cannot be performed on site, a new test, the Platelia, is now easily included in any laboratory and is indicated particularly for early-acute phase samples. [14] To investigate the frequency of dengue and malaria co-infection, the Platelia test should be used in all cases of dengue-like or malaria-like syndrome, even when malaria diagnosis was positive, in regions w here both infections may overlap. Both dengue fever and malaria can present with thrombocytopenia. Thrombocytopenia is a consistent finding in dengue fever and is regarded as a strong predictor of dengue fever. [6] Thrombocytopenia is also considered criterion of disease severity, bad prognostic factor and its presence is associated with increase probability of malaria. [7, 8] Mixed infections with many etiologic agents are not uncommon in malaria. [15] Despite scant data, dengue and malaria coinfection should be common in areas where both diseases are co-endemic in many places of the world. [16] In a study regarding diagnostic techniques and management of dengue and malaria co-infection, all patients with dual infection presented prolonged fever for more than seven days, myalgia, bleeding manifestations, rash and anemia. [17] Moreover, according to Vasconcelos et al, the continuous fever caused by arboviral infection can mask the periodic fever associated with malarial parasites. [18] Out of 159 thrombocytopenic cases presented with acute febrile illness, malaria was diagnosed in 55 (34.6%) cases while 34 (21.4%) of cases were diagnosed as dengue. Of the 89 patients of dengue and malaria in this study, 5.6% had concurrent dengue and malaria. This percentage is relatively high as compared with other international studies. A study from France reported that 1% concurrent dengue and malaria. [19] Another study from Brazil reported 1.8% concurrent dengue and malaria. [20] Very high percentage was found in a local study Ali et.al showed that Out of 11 patients diagnosed as having dengue fever on serology 9 (81.8%) also had co-existence of malaria and thrombocytopenia was present in 90% of such patients. [5] In this study from 9 positive cases of co-infection, 3 (60%) were male and 2 (40%) were female. Mean ( ±SD) age of positive cases of co-infection was 37.8 ( ±8.3) years. Although a reduced sample number was assessed in this study, a limitation that we acknowledge, it is important to remember that dengue and malaria co-infection requires special attention because delayed diagnosis and appropriated treatment can result in fatal complications. [16, 21] Both diseases causes similar symptoms and simultaneous infections with two different infectious agents may result in overlapped symptoms, [22] diagnosis of malaria and dengue based purely on clinical grounds may become difficult for physicians [16] and it is possible that either clinical spectrum of the disease or treatment may also be affected. [23] Finally, it is important to remember that both diseases have similar clinical findings, thus the diagnosis could be made concomitantly for dengue and malaria in patients living or returning from areas where both diseases are endemic or during dengue outbreaks. CONCLUSION Concurrent infections were found 5.7% in this study. Although this percentage is slightly low; special attention should be given to the possibility of co-infection with malaria and dengue. The distinction between severe dengue and severe malaria must be made in an emergency department or hospital setting because in both situations, early diagnosis is essential for patient care. Finally, it is important to remember that both diseases have similar clinical findings, thus the diagnosis could be made concomitantly for dengue and malaria in patients living or returning from areas where both diseases are endemic or during dengue outbreaks. Acknowledgement: We would like to acknowledge faculty of Ziauddin Hospital, North Campus for helping us during the study, staff for helping in data collection and all others who have given their input. REFERENCE Rigau-Perez JG, Clark GG, Gulber DJ, Reitee P, Sanders EJ, Vorndam AV. Dengue and dengue hemorrhagic fever. Lancet 1998;352:971-7. Henchal EA, Putnak JR. The dengue viruses. Clin Microbiol Rev 1990;3: 376-96. Pinheiro FP, Corber SJ. Global situation of dengue and dengue hemorrhagic fever and its emergence in Americas. World Health Stat 1997;50:161-9. Guzman MG, Kouri G. Dengue: an update. Lancet infect Dis 2002;2:33-42. Ali N, Nadeem A, Anwar M, Tariq WZ, Chotani RA. Dengue fever in malaria endemic areas. J Coll Physicians Surg Pak 2005;16:340-42. Ahmed S, Ali N, Ashraf S, Ilyas M, Tariq WZ, Chotani RA. Dengue fever outbreak: A clinical management experience. J Coll Physicians Surg Pak 2008;18:8-12. Mahmood A, Yasir M. Thrombocytopenia; a predictor of malaria among febrile patients in Liberia. Infect Dis J Pak 2005;14:41-4. Lathia TB, Joshi R. Can hematological parameters discriminate malaria from nonmalarious acute febrile illness in the tropics? Indian J Med Sci. 2004;58:239-44. Charrel RN, Brouqui P, Foucault C, de Lamballerie X. Concurrent dengue and malaria. Emerg Infect Dis. 2005;11:1153–4. Deresinski S. Concurrent Plasmodium vivax malaria and dengue. Emerg Infect Dis. 2006;12:1802. Thangaratham PS, Jeevan MK, Rajendran R, Samuel PP, Tyagi BK. Dual infection by dengue virus and Plasmodium vivax in Alappuzha District, Kerala, India. Jpn J Infect Dis. 2006;59:211–2. Ward DI. A case of fatal Plasmodium falciparum malaria complicated by acute dengue fever in East Timor. Am J Trop Med Hyg. 2006;75:182–5. Allwinn R. Doerr HW, Emmerich P, Schmitz H, Preiser W. Crossreactivity in fl avivirus serology: new implications of an old fi nding? Med Microbiol Immunol. 2002;190:199–202. Dussart P, Labeau B, Lagathu G, Louis P, Nunes MR, Rodrigues SG, et al. Evaluation of an enzyme immunoassay for detection of dengue virus NS1 antigen in human serum. Clin Vaccine Immunol. 2006;13:1185–9. Singhsilarak T, Phongtananant S, Jenjittikul M, Watt G, Tangpakdee N, Popak N, et al. Possible acute coinfections in Thai malaria patients. Southeast Asian J Trop Med Public Health 2006;37:1-4. Ward DI. A case of fatal Plasmodium falciparum malaria complicated by acute dengue fever in East Timor. Am J Trop Med Hyg 2006;75:182-5. Abbasi A, Butt N, Sheikh QH, Bhutto AR, Munir SM, Ahmed SM. Clinical Features, Diagnostic Techniques and Management of Dual Dengue and Malaria Infection. J Coll Physicians Surg Pak 2009;19:25-9. Vasconcelos PFC, Rosa APAT, Rosa JFST, Dà ©gallier N. Concomitant Infections by Malaria and Arboviruses in the Brazilian Amazon Region. Rev Latinoam Microbiol 1990;32:291-4. Carme B, Matheus S, Donutil G, Raulin O, Nacher M, Morvan J. Concurrent Dengue and Malaria in Cayenne Hospital, French Guiana. Emerg Infect Dis 2009;15:668-71. Santana VD, Lavezzo LC, Mondini A, Terzian AC, Bronzoni RV, Rossit AR et al. Concurrent dengue and malaria in the Amazon region. Rev Soc Bras Med Trop 2010;43:508-11 Charrel RN, Brouqui P, Foucault C, Lamballerie X. Concurrent Dengue and Malaria. Emerg Infect Dis 2007;11:1153-4. Bhalla A, Sharma N, Sharma A, Suri V. Concurrent infection with Dengue and Malaria. Indian J Med Sci 2006;60:330-1. Tangaratham PS, Jeevan MK, Rajendran R, Samuel PP, Tyagi BK. Dual Infection by Dengue Virus and Plasmodium vivax in Alappuzha District, Kerala, India. Jpn J Infect Dis 2006;59:211-2.

Contrasts in Stopping by Woods on a Snowy Evening :: Stopping Woods Snowy Evening

Contrasts in 'Stopping by Woods'    The duality of the narrator's response to the woods is caught in the contrast between the relaxed, conversational idiom of the first three lines (note the gentle emphasis given to ‘think', the briskly colloquial ‘though') and the dream-like descriptive detail and hypnotic verbal music ('watch . . . woods', 'his . . . fill . . . with') of the last. Clearing and wilderness, law and freedom, civilization and nature, fact and dream: these oppositions reverberate throughout the poem. Frost develops his   own quietly ironic contrast between the road along which the narrator travels, connecting marketplace to marketplace, promoting community and culture - and the white silence of the woods, where none of the ordinary limitations of the world seem to apply. In a minor key, they are caught also in the implicit comparison between the owner of these woods, who apparently regards them as a purely financial investment (he lives in the village) and the narrator who sees them, at leas t potentially, as a spiritual one.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   This contrast between what might be termed, rather reductively perhaps, 'realistic' and 'romantic' attitudes is then sustained through the next two stanzas: the commonsensical response is now playfully attributed to the narrator's horse which, like any practical being, wants to get on down the road to food and shelter. The narrator himself, however, continues to be lured by the mysteries of the forest just as the Romantic poets were lured by the mysteries of otherness, sleep and death. And, as before, the contrast is a product of tone and texture as much as dramatic intimation: the poem communicates its debate in how it says things as much as in what it says. So, the harsh gutturals and abrupt movement of lines like, 'He gives his harness bells a shake / To ask if there is some mistake', give verbal shape to the matter-of-fact attitude attributed to the horse, just as the soothing sibilants and gently rocking motion of the lines that follo w this ('The only other sound's the sweep / Of easy wind and downy flake') offer a tonal equivalent of the strange, seductive world into which the narrator is tempted to move. 'Everything that is written', Frost once said, 'is as good as it is dramatic'; and in a poem like this the words of the poem become actors in the drama.

Gender Issues in Sri Lanka Essay

Gender issues In general, when considering third world countries, most would say that they have some very similar characteristics. Third world countries are often thought of as places that are impoverished, have significantly high birthrates, are economically dependent on advanced countries, and have not evolved socially in regards to equal rights issues. Although many of these characteristics do apply to Sri Lanka, the latter has definitely evoked some discussion on the topic of gender issues in underdeveloped countries. Issues such as decision making in the household, educated women and their role in society, and attitudes towards women in employment will be discussed. As stated earlier, most would agree that from a distant perspective Sri Lanka would seem to be socially underdeveloped in regards to equal rights. One way that this misconception is debunked is by looking at the roles of male and female in the household. There are many variables to take into consideration when looking at roles of family members and who has the balance of power; for instance, if the wife is working or not could be considered at both ends of the scale. If she is working than her husband may feel that because she is making a financial contribution she has more of a right to make important economic decisions that may effect the family. On the other hand he may feel as though her being away from the children is a detriment to their upbringing, and in turn is placing a burden upon the family leaving the wife with few domestic decisions. Another variable that has to be considered is if the residence is with the husband’s family or if it is with the wife’s family. In this case one would assume that whichever house was being resided in would have the balance of the say towards family decisions. The last variable that will be considered is that of marital duration. Does a longer marriage necessarily mean that the financial and domestic decisions of the household will become split evenly between the husband and wife? The answers to these questions were the focus of a study conducted by Anju Malhotra and Mark Mather in 1992. The study showed that when the wives were working, regardless of whether or not they shared their wages or kept them, they had an increase say on financial matters. However, the domestic decisions were not nearly as great, especially if the wages earned by the wife were kept for herself (Malhotra et al. 1997: 620). When looking at the balance of power in regards to household arrangement, the study found that the wife had almost no say on financial matters when living at the husband’s parents house but did have some say on domestic issues. The opposite it true for when the family resided at the wife’s parents house. The wife typically had a significant say on financial and domestic matters with the latter outweighing the two (Malhotra et al. 1997: 620). As far as marital duration is concerned, it seems as though as the family grows together there is somewhat of a role reversal. The husband becomes more concerned with domestic matters and the wife takes some responsibility for the financial decisions (Malhotra et al. 1997:620). These findings led my research group to believe that the people of Sri Lanka are generally very similar to those of western societies in regards to household decisions. Education is not something we think about when speaking about developing countries, many assume that it is just not an option for underprivileged people. Although that is the unfortunate truth that effects many third world countries, it does seem that Sri Lanka is on its way to recovering itself. For many years the gender gap between male and female scholars needed to be decreased. In the early 1980’s the percentage of the total amount of people with university degrees that were women was barely above 40%. A more alarming fact might be that the percentage with post-graduate degrees was barely above 25% (Ahooja-Patel K. 1979: 217). The majority of women pursuing a degree usually did so in the fine arts category or the education and teacher training fields, many staying away from disciplines such as business or engineering. Although these numbers may seem staggering Sri Lanka has shown some promise in terms of social welfare. Programs are now in place to encourage female education and to decrease the inequalities women face today. In the early 1990’s the gender gap between literate males and females was only a 5% difference (Malhotra et al. 1997: 602). Many believe that the more westernized Sri Lanka becomes the more independent the thoughts and wills of women will expand, creating a country of little inequality. Women in the work force today in western society face many barriers; this is after years of trying to refine the social economic status of women. In Sri Lanka, because of its poor economy, employers may have actual complaints that may affect the profitability of their business. In general in Sri Lanka, men are usually preferred over women as employees. Some employers complain that because of the possibility of the need for time off to bear children that it may disrupt the flow of the work force. Many men could feel as though women were being treated with undeserved favoritism, which could cause conflict. Others feel that the financial burden of having to install proper facilities to accommodate women could create too much of a loss that they would not be able to overcome it. The topic of most discussions seems to revolve around the Maternity Amendment Act of 1978, which states that women workers are entitled to six weeks maternity leave with pay. It also states that they are allowed two nursing breaks of one hour each or two breaks of one half hour each when a day care center is available (Ahooja-Patel K. 1979: 219). Women cannot, under the law, be fired for any reason that stems from them being pregnant. An unfortunate fact that is slowly being eradicated is that many women are just not qualified for the jobs that are available in Sri Lanka. Because of the gender gap in education and training that has plagued Sri Lanka for years this trend will surely continue until the inequality has subsided. In many ways Sri Lanka has come very far in terms of gender equality when discussing kinship and education. However, women’s economic situation has shown to be less favourable. The people of Sri Lanka acknowledge that women have a place in the work force but financially cannot accommodate them. Until the economic growth of Sri Lanka can develop further, people will continue to have the ‘survival of the fittest’ kind of attitude, which will continue to alienate and repress the women or Sri Lanka.

Name the Strong Acids and Worlds Strongest Acid

Name the Strong Acids and World's Strongest Acid Most of the standardized tests students take, like the SAT and GRE, are based on your ability to reason or to understand a concept. The emphasis isnt on memorization. However, in chemistry there are some things you just have to commit to memory. Youll remember the symbols for the first few elements and their atomic masses and certain constants just from using them. On the other hand, its harder to remember the names and structures of the amino acids and the strong acids. The good news, regarding the strong acids, is any other acid is a weak acid. The strong acids dissociate completely in water. Strong Acids You Should Know HCl - hydrochloric acidHNO3 - nitric acidH2SO4 - sulfuric acidHBr - hydrobromic acid HI - hydroiodic acidHClO4 - perchloric acid The Worlds Strongest Acid Although this is the strong acid list, probably found in every chemistry text, none of these acids hold the title of Worlds Strongest Acid. The record-holder used to be fluorosulfuric acid (HFSO3), but the carborane superacids are hundreds of times stronger than fluorosulfuric acid and over a million times stronger than concentrated sulfuric acid. The superacids readily release protons, which is a slightly different criterion for acid strength than the ability to dissociate to release a H ion (a proton). Strong Is Different from Corrosive The carborane acids are incredible proton donors, yet they are not highly corrosive. Corrosiveness is related to the negatively-charged part of the acid. Hydrofluoric acid (HF), for example, is so corrosve it dissolves glass. The fluoride ion attacks the silicon atom in silica glass while the proton is interacting with oxygen. Even though it is highly corrosive, hydrofluoric acid is not considered to be a strong acid because it does not completely dissociate in water.Strength of Acids Bases | Titration Basics

The Great Gatsby & Hollow Men essays

The Great Gatsby & Hollow Men essays The Great Gatsby has been one of the classic novels of the twentieth century. It creates a unique society that makes the story such a masterpiece. Another magnificent work that relates to The Great Gatsby is T.S. Eliots The Hollow Man. The lines in the poem portray the story so vividly that it should have been an epigraph for the novel. The poems references to hollow and stuffed men, can describe different characters in The Great Gatsby. The hollowness of men represents ruthless barbarians with no respect for humans and no understanding of love. However, the stuffed men seem to be educated, wealthy, and respectful. The differences in these types of men can be seen through the events of the novel. Another aspect of the poem that represents the novel is the idea of the paralyzed force. This force symbolizes freedom and uniqueness. It also is captivating and serves as authority. So, the similarities between The Great Gatsby and The Hollow Men remarkably show the hollow and stuffed chara cteristic of the people in Gatsbys secret society. The first similarity between the two pieces of work is the hollowness in mankind referred to by the poem. In the novel there are two main characters that depict such hollowness. The antagonistic character of Tom Buchanan represents the ruthless and careless American whose dream is to use women and acquire money. In addition he has no respect towards others, which creates pain for people around him. An example of this is when Myrtle repeatedly uttered his wifes name, which was Daisy. Tom took this as an insult and viciously punched her in the nose. He never took into consideration that hitting a woman is uncivilized. Another quality he has is to flaunt his wealth in other peoples faces. This can be seen when he takes Nick around his colossal house. Tom wants others to feel jealous of his riches, when he is actually jealous of the others around him. Th...

Causes of Financial Globalisation and Its Consequences on Developing Essay

Causes of Financial Globalisation and Its Consequences on Developing Countries - Essay Example According to Sergio (2004), in the last one hundred years, only a few countries and sectors participated in financial globalization by which capital flows tended to follow migration and was generally directed toward supporting trade flows. Capital flows took the form of bonds, and the flows were of a long-term nature. International investment was dominated by a small number of freestanding companies, and financial intermediation was concentrated in a few family groups. The international system was dominated by the gold standard, in which gold was used to backed national currencies. The turn around things came at the heals of the effects of the first world war and the great depression that saw governments reversed their position on financial globalization, and were now imposing capital controls in order to regain monetary policy autonomy with the 1950s and 1960s witnessing the lowest capital flows. This all happened because the Bretton Woods had dominated the international system and used a system of fixed but adjustable exchange rates, limited capital mobility, and autonomous monetary policies that seriously affected the developing counties. But the developing countries saw the light of day when the 1973 oil crisis shock the international community and at that time, the Bretton Woods system of fixed exchange rates break down giving the leeway for international banks with fresh funds to invest in developing countries mainly in the areas of financing public debt in the form of syndicated loans. Developing countries at that time were able to open up new avenues for capital mobility while at the same time maintaining their autonomous monetary systems.

MGMT305 U3 IP Research Paper Example | Topics and Well Written Essays - 750 words

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