Prevalence of ESBL in Surgical Wound Infections and Burns

Prevalence of ESBL in Surgical Wound Infections and Burns PREVELANCE OF EXTENDED SPECTRUM BETA LACTAMASES PRODUCERS AMONG SURGICAL WOUND INFECTIONS AND BURNS PATIENTS AT DR. SHANKARRAO CHAVAN GOVERNMENT MEDICAL COLLEGE, NANDED. *Vivek M Gujar1, Sharmila S Raut2, Sanjaykumar R More3 1. Assistant Professor, Dept. of Microbiology, Dr. S.C. Government Medical College, Nanded. 2. Professor, Dept. of Microbiology, Dr. S.C. Government Medical College, Nanded. 3. Associate Professor, Dept. of Microbiology, Dr. S.C. Government Medical College, Nanded. ABSTRACT Purpose:- The purpose of this study was to know the prevalence of Extended Spectrum beta lactamases (ESBL) among surgical wound infection and burn patients. Methods:- A total of 100 patients admitted to the surgical wards with post operative wound infections and burns from January 2014 to May 2014 were studied. A total of 137 isolates were obtained from these patients. Of these, 87 organisms (63.5% of the total isolates) were found to be Extended Spectrum beta lactamases (ESBL) producers. The commonest were Escherichia coli and Klebsiella pneumonia . They were studied for ESBL production by screening test, CLSI disc diffusion method phenotypic confirmation by disc potentiation test. Result:- Out of 100 strains, 87 (63.5%) were confirmed as ESBL producers. Among the ESBL producer all the isolates were sensitive to Imipenem. Resistance against Ampicillin (10ug) is 100%, Gentamicin (10ug) is 80.46%, Ciprofloxacin (5ug) is 74.72%, Tetracycline(30ug) is 63.22% and Amikacin (30ug) is 16.1 0.% Conclusion:- Our study shows presence of ESBL producer among surgical wound infections and burn patients and their prevalence is 63.5%. The routine antimicrobial sensitivity test may fail to detect ESBL. Detection of ESBL production should be carried out as a routine in diagnostic laboratories by disc potentiation test as it is a simple and cost effective test. Antibiotics resistance is significantly more prevalent in ESBL positive isolates as compared to ESBL negative. Key words:- Extended Spectrum Beta Lactamases, ESBL, INTRODUCTION The beta lactam antibiotics are amongst the most widely prescribed antibiotics and are an important component of empirical therapy in intensive care unit and high risk ward.1,2,3 Resistance to beta lactam antibiotics is an increasing problem worldwide.4 Increase in the prevalence of penicillin resistance in Streptococcus pneumoniae, Methicillin resistance in Staphylococcus aureus, Vancomycin resistance in Enterococci, Extended spectrum beta lactamases (ESBL) production in Enteric Gram negative bacilli and Fluroquinolone resistance in Neisseria gonorrhoea are just a few examples of the rising problem of resistance documented by both national and international surveillance system in the past few years.5 The ESBL are plasmid mediated enzymes that hydrolyze the oxyimino beta lactam (3rd generation cephalosporine) and monobactam (aztreonam), but have no effect on cephamycins (cefoxitin and cefotatan). It is situated in periplasmic space.6 Although TEM type beta lactamases are most often found in Escherichia coli and Klebsiella pneumoniae, they are also found in Enterobacter spp., Salmonella spp., Morganella morganii, Proteus mirabilis, Serratia marcescens, Pseudomanas aeruginosa, Shigella dysenteriae, Capnocytophaga ochracea and Citrobacter 7,8,9,10. However, the frequency of ESBL production in these organisms is low.11 Over 150 different ESBLs have been described as of today.12 ESBL pose a major problem for clinical therapeutic. It is necessary to identify the prevalence of these strain in hospitals and to characterise their epidemiology, control spread of these strains and to determine suitable preventive measures and treatment policies. MATERIALS AND METHODS A present study was conducted at Dr. Shankarrao Chavan Government Medical College, Nanded between January 2014 – May 2014. A total number of 100 post operative wound infections and burns patients wound swabs were processed during the study. A total of 137 isolates were obtained from these patients. COLLECTION AND IDENTIFICATION OF THE ISOLATES Using aseptic precautions, wound swabs were collected from the patients using sterile tipped swabs. The organism(s) isolated were identified based on colony morphology on blood agar, MacConkey agar and by standard biochemical tests.13,14 Strains:- Escherichia coli ATCC 25922( ESBL negative) and Klebsiella pneumoniae ATCC 700603 (ESBL positive)were used as control organism throughout the study. Antimicrobial Susceptibility testing:- The antibiotic sensitivity test was performed by Kirby Bauer disc diffusion technique with commercial available discs (HiMedia, Mumbai, India) on Muller Hinton agar plates. The discs used were Ampicillin (10ug), Amikacin (30ug), Gentamicin (10ug), Ciprofloxacin (5ug), Imipenem (10ug) and Tetracycline (30ug). The diameter of the zone of inhibition of each antibiotic was measured and interpreted as sensitive, intermediate sensitive or resistance according to CLSI criteria.15 Detection of ESBL15:- In the present study 137 isolates were tested for ESBL production by the following methods- SCREENING TESTS15:- CLSI disc diffusion method PHENOTYPIC CONFIRMATION TEST15:- Disc potentiation test CLSI ESBL Screening test:- 15 According to NCCLS 2002 for screening test to be positive or to consider an organism as probable ESBL producer the zone diameter should be- Antibiotic Zone diameter In mm or less Ceftazidime(30ug) 22 Cefotaxime (30ug) 27 Ceftriaxone (30ug) 25 Cefpodoxime(10ug) 17 Aztreonam (30ug) 27 The use of more than one antimicrobial agent suggested for screening will improve the sensitivity of ESBL detection15. Ideally the most sensitive ESBL screening agent is Cefpodoxime for Escherichia coli and Klebsiella pneumoniae.9 In the present study, ceftazidime (30ug), cefotaxime (30ug), ceftriaxone(30ug), cefpodoxime (10ug) and aztreonam (30ug) were used. These were stored in refrigerator. Before use they were taken out of refrigerator and brought to room temperature. Then they were applied on Muller Hinton agar for Antibiotic sensitivity testing. DISC POTENTIATION METHOD 15 As per CLSI guidelines disc potentiation method was used as phenotypic confirmatory test. For confirmation of ESBL production ceftazidime (30ug), ceftazidime + clavulanic acid combination disc (30/10ug) manufactured by HiMedia and cefotaxime (30ug) + cefotaxime clavulanic acid (30/10ug) prepared in laboratory were used. PREPARATION OF CLAVULANIC ACID STOCK SOLUTION For preparation of clavulanic acid stock solution Augmentin powder (gsk company) was used- 1.2gm vial of (Augmentin) contains 200mg clavulanic acid 1200 mg contains 200mg clavulanic acid Therefore, 6 mg Augmentin contains 1 mg clavulanic acid. 6 mg Augmentin is dissolved in 1 ml sterile distilled water to make a solution i.e 1ml solution contain 1 mg clavulanic acid. i.e 1000ul solution contains 1000ug clavulanic acid. PREPARATION OF CEFOTAXIME-CLAVULANIC ACID DISC15,16 Cefotaxime (30ug) discs were kept separately in a sterile petridish. 10ul of stock solution of clavulanic acid was added to each disc with a micropipette. 30 minutes were allowed for clavulanic acid to absorb and also for the disc to dry. The discs were used immediately after preparation. STORAGE OF CEFTAZIDIME+CLAVULANIC ACID DISC Clavulanic acid being labile, discs were placed in separate screw capped glass vials and stored at -200C. When antibiotics discs were required for test, they were removed from the freezer and allowed to come to room temperature before application. 17 APPLICATION OF DISCS:- After preparing the inoculum, Muller Hinton agar plates were inoculated. With the help of sterile forcep antibiotic discs containing ceftazidime and ceftazidime+clavulanic acid and cefotaxime and cefotaxime+clavulanic acid were placed on inoculated Muller Hinton agar plate at a distance of 24 mm from center to center. Plates were inverted and incubated at 370C for 16-18 hours. INTERPRETATION More than or equal to 5mm increase in a zone diameter for ceftazidime and cefotaxime tested in combination with clavulanic acid versus its zone when tested alone indicate ESBL production. ESBL POSITIVE:- If an isolate is confirmed as ESBL producer, the isolate reported as resistant to all Penicillin, Cephalosporins and Monobactam (Aztreonam). ESBL NEGATIVE:- If an isolate is not confirmed as ESBL producer, the sensitivity of the isolate was reported as per sensitivity test report. RESULT The total number of patients screened were 100 of which 64 were males and 36 females (M : F = 1.78:1). The average age was 44.72 years (Range 12-80 years). The types of wounds were post operative wounds (65.7%) and burns (34.3%). Duration of hospital stay ranged from 15 days to 3 months. Out of 137 strains, 87 (63.50%) were confirmed as ESBL producers (Table 1). Susceptibility pattern of the ESBL producers were studied. All the isolates were sensitive to Imipenem. Resistance against Ampicillin (10ug) is 100%, Gentamicin (10ug) is 80.46%, Ciprofloxacin (5ug) is 74.72%, Tetracycline(30ug) is 63.22% and Amikacin (30ug) is 16.10.% (Table 3). TABLE 1 Distribution of ESBL strains among the different organisms isolated Sr. no Organism No. of organisms Isolated No. of ESBL strains % ESBL strains 1 Escherichia coli 71 45 63.38% 2 Klebsiella pneumonia 57 36 63.15% 3 Enterobacter spp. 07 04 57.14% 4 Morganella morganii 01 01 100% 5 Providentia rettgeri 01 01 100% TOTAL 137 87 63.50% Table 2 Distribution of ESBL strains based on clinical diagnosis Sr. no Clinical diagnosis No. of organisms Isolated No. of ESBL strains % ESBL strains 1 Post operative wounds Infections 90 55 61.11% 2 Burns 47 32 68.08% Table 3 Antimicrobial susceptibility pattern of ESBL positive strains Sr. no Organism Susceptibility Category A Ak G Cf T I 1 Escherichia coli (45) S 00 37 07 10 18 45 IS 00 05 02 01 02 00 R 45 03 36 34 25 00 2 Klebsiella pneumonia (36) S 00 30 05 07 10 36 IS 00 02 02 02 01 00 R 36 04 29 27 25 00 3 Other. (06) S 04 06 05 05 04 06 IS 00 00 00 01 01 00 R 02 00 01 00 01 00 A=Ampicillin, Ak = Amikacin, Cf = Ciprofloxacin, G = Gentamicin, T = Tetracycline, I = Imepenem, R= Resistance, S = sensitive, IS = Intermediate sensitive DISCUSSION The prevalence of ESBL among clinical isolates very greatly worldwide, indifferent geographic areas and are rapidly changing overtime.18 In, 1983, Knothe et.al describe for the first time transferable resistance to the broad spectrum cephalosporins in clinical isolates of Klebsiella pneumoniae.19 The routine susceptibility test done by clinical laboratories fail to detect ESBL positive strains. The incidence of ESBL producing organisms in various studies has varied from 0-84%. In our study prevalence of ESBL producing strains is found to be 63.5%. All ESBL producers were sensitive to Imipenem. The result is in accordance with observation reported by other investigators.3,12,18,20 The new inhibitor based confirmatory test approach has been recommended by the CLSI for detection of ESBL. In the present study we found disc potentiation method to be reproducible, sensitive, easy and cost effective for use in a busy diagnostic laboratory.3,11 The use of both cefotaxime and ceftazidime with and without clavulanic acid increases the sensitivity of detection of ESBL compared to the use of only one of them. Inclusion of Cefpodoxime has been reported to further increase the sensitivity of this tests. 3,11 Among the Enterobacteriaceae, ESBL are most prevalent in Escherichia coli and Klebsiella spp. isolates. CONCLUSION The prevalence of ESBL producing strains is 63.5%. Multidrug resistance was found to be significantly higher in ESBL positive isolates as compared to ESBL negative. All the ESBL producers are sensitive to Imipenem. If an isolate is confirmed as ESBL producer, the isolate reported as resistant to all Penicillin, Cephalosporins and Monobactam (Aztreonam). Detection and reporting of beta lactamases producer is responsibility of every clinical Microbiologist. To prevent the spread of ESBLs producing organisms, infection control precautions like barrier nursing, cohorting of patients and nurses, attention to hand washing are essential. REFRENCES Chambers H F, Neu H C, Other beta lactam antibiotics In:Mandell G L, Bennetts J E, Daolin R, editors. Principles and Practice of infectious diseases 4th ed. Vol.I, New york: Churchill Livingstone;1995p.264-72. Fatima H M,, Chanawong A, Kevin G K, Birkenhead D and Hawkey P M. Detection of extended spectrum beta lactamases in members of the family Enterobacteriaceae: comparision of the MAST DD test, the double disc and Etest ESBL. J antimicrob Chemother (2000) 45: 881-885. Mathur P, Kapil A, Das B and Dhawan B. Prevalence of extended spectrum beta lactamases producing Gram negative bacteria in a tertiary care hospital. Indian J Med Res (2000) 115: 153-157. Samaha-Kfoury J N and Georges F A. Recent development in beta lactamases and extended spectrum beta lactamases. British Med J (2003) 327: 1209-1213. Tenover F C, Mohammed M J, Stelling J, O’brien T and Williams R. Ability of Laboratories To Detect Emerging Antimicrobial Resistance: Proficiency Testing and Quality Control Results from the World Health Organisation’s External Quality Assurance System for Antimicrobial Susceptibility Testing. J Clin Microbiol (2001) 39(1):241-250. Louis Rice, MD. Evolution and Clinical Importance of Extended Spectrum beta Lactamases. CHEST (2001) 119: 391S-396S. Decre D, Guchot B, Lucet C, Guillaume A, Bergogne B and Regnier B. Clinical and Bacteriologic Epidemiology of Extended Spectrum beta Lactamases Producing Strains of Klebsiella pneumoniae in a Medical Intensive Care Unit. Clin Infect Dis (1998) 27: 834-844. Thomas K S. Controversies about Extended Spectrum and AmpC beta Lactamases CDC (2001) 7(2): 1-9. Rodrigues C, Joshi P, Jani S H, Alphonse M, Radhakrishanan Ramd Mehta A, DETECTION OF BETA LACTAMASES IN NOSOCOMIAL GRAM NEGATIVE CLINICAL ISOLATES. Indian J Med Microbiol (2004) 22(4): 247-250. Tankhiwale S S, Jalgaonkar S V, Sarfraz Ahmed and Hassani U. Evaluation of extended spectrum beta lactamases in urinary isolates. Indian J Med Res (2004) 120: 553-556. Chaudhary U and Aggarwal R. EXTENDED SPECTRUM BETA LACTAMASES (ESBL) – AN EMERGING THREAT TO CLINICAL THERAPEUTICS. Indian J Med Microbiol (2004) 22(2): 75-80. Menon T, Bindu D, Kumar CPG, Nalini S and Thirunarayan M A. COMPARISON OF DOUBLE DISC AND THREE DIMENSIONAL METHODS TO SCREENING FOR ESBL PRODUCERS IN A TERTIARY CARE HOSPITAL. Indian J Med Microbiol (2006) 24: 117-120. Betty A Forbes, Daniel F Sahm, Alice S Weissfeld. Laboratory cultivation and isolation of bacteria. In: K.Fabiano, Sarahly L, Ellen Wurm, editors. Bailey and Scott’s Diagnostic Microbiology, 11th ed. Mosby Elesvier; (2002): 133-147. Koneman E W, Allen S D, Janda M W, Schreckenberger P C and Wine W C. The Enterobacteriaceae. In: Andrew A, Collins H and Deitch S editors. COLOUR ATLAS AND TEXTBOOK OF DIAGNOSTIC MICROBIOLOGY, 5th ed. Philadelphia: J b Lipincott Co. 1991: 105-184. National Committee for Clinical Laboratory Standards (NCCLS). Performance Standards for Antimicrobial Susceptibility Testing. Twelth Information Supplement 2002. M100-S12. Vol.20 No.1 2 Villanova Pa. Steward C D, Rasheed J K, Hubert S K, Biddble J W, Raney P M, Anderson G J, Williams P P, Brittain K L, Oliver A, McGowan J E and Tenover F C. Characterization of clinical isolates of Klebsiella pneumoniae from 19 laboratories using the National Committee for Clinical Laboratory Standard Extended spectrum beta Lactamases Detection methods. J Clin Microbiol (2001) 39(8): 2864-2872. Watt C, Louie M, simor A E. Evaluation of Stability of Cefotaxime(30ug) and Ceftazidime(30ug) discs impregnated with clavulanic acid(10ug) for detection of Extended spectrum beta Lactamases. J Clin Microbiol (2000) 38(7): 2796-2797. Babypadmini S and Appalaraju B. EXTENDED SPECTRUM BETA LACTAMASES IN URINARY ISOLATES OF ESCHERICHIA COLI AND KLEBSIELLA PNEUMONIAE – PREVALENCE AND SUSCEPTIBILITY PATTERN IN A TERTIARY CARE HOSPITAL. Indian J Med Microbiol (2004) 22(3): 172-174. Liu P Y, Jai-Chain T, Se-Chin Ke and Chen S L. Molecular Epidemiology of Extended Spectrum beta Lactamases producing Klebsiella pneumoniae Isolates in District Hospital in Taiwan. J Clin Microbiol (1998) 36(9): 2759-2762. Shukla I, Tiwari R and Agarwal M. PREVALENCE OF EXTENDED SPECTRUM BETA LACTAMASE PRODUCING KLEBSIELLA PNEUMONIAE IN A TERTIARY CARE HOSPITAL. Indian J Med Microbiol (2004) 22(2): 87-91.

Hawthornes Young Goodman Brown and its Author Essay -- Young Goodman

     Ã‚   Initially, of course, Nathaniel Hawthorne’s literary works went unranked among those of other American and British writers. But his reputation grew gradually even among contemporary critics, until he was recognized as a â€Å"man of genius.† Edgar Allen Poe, in a review of Hawthorne’s â€Å"Young Goodman Brown,† which had been written 12 years prior, said in Godey's Lady's Book, November, 1847, no. 35, pp. 252-6: It was never the fashion (until lately) to speak of him in any summary of our best authors. . . . The "peculiarity" or sameness, or monotone of Hawthorne, would, in its mere character of "peculiarity," and without reference to what is the peculiarity, suffice to deprive him of all chance of popular appreciation. But at his failure to be appreciated, we can, of course, no longer wonder, when we find him monotonous at decidedly the worst of all possible points--at that point which, having the least concern with Nature, is the farthest removed from the popular intellect, from the popular sentiment and from the popular taste. I allude to the strain of allegory which completely overwhelms the greater number of his subjects. So literary critic Edgar Allan Poe thinks that Hawthorne’s heavy reliance on allegory is the cause of his lack of popularity during the 1830’s and 40’s. In 1848 James Russell Lowell wrote a piece of poetry entitled â€Å"Hawthorne† for the periodical A Fable for Critics:   Ã‚  Ã‚  Ã‚   "There is Hawthorne, with genius so shrinking and rare   Ã‚  Ã‚  Ã‚   That you hardly at first see the strength that is there;   Ã‚  Ã‚  Ã‚   A frame so robust, with a nature so sweeet,   Ã‚  Ã‚  Ã‚   So earnest, so graceful, so lithe and so fleet,   Ã‚  Ã‚  Ã‚   Is worth a descent from Olympus to meet;   Ã‚  Ã‚  Ã‚   'Tis as if a rough oak that for ages ha... ..... Yesterdays With Authors. 1871. http://eldred.ne.mediaone.net/nh/ywa3.html    â€Å"Hawthorne and His Mosses.† The Norton Anthology: American Literature, edited by Baym et al.   New York: W.W. Norton and Co., 1995.    Hawthorne, Nathaniel. The Complete Short Stories of Nathaniel Hawthorne. New York: Doubleday and Co., Inc.,1959.    James, Henry. Hawthorne. Ithaca, NY: Cornell University Press, 1997.    James, Henry. â€Å"Nathaniel Hawthorne,† Nation, March 14, 1872. http://eldred.ne.mediaone.net/nh/hjnat.html    Longfellow, Henry Wadsworth. â€Å"Hawthorne- 1804-1864.† 1864. http://eldred.ne.mediaone.net/nh/nhlong.html    Lowell, James Russell. â€Å"Hawthorne.† In A Fable For Critics. 1848. http://eldred.ne.mediaone.net/nh/fable.html    Melville, Herman. â€Å"Hawthorne and His Mosses,† The Literary World August 17, 24, 1850.      

Racism in euroropean football Essay

Medieval football matches involved hundreds of players, and were essentially pitched battles between the young men of rival villages and towns often used as opportunities to settle old feuds, personal arguments and land disputes. The much more disciplined game introduced to continental Europe in 1900s was the reformed pastime of the British aristocracy. Other European countries adopted this form of the game, associated with Victorian values of fair-play and retrained enthusiasm. Only two periods in British history have been relatively free of football-related violence: the inter-war years and the decade following the Second World War. Recently it seems more and more becoming that racism is beginning to damage the reputation of the game. Racism isn’t directed at players simply because of their skin colour; players are also targeted because of their nationality, religion or ethnicity. Some players may be targeted by football supporters more because they play for an opposing team rather than their appearance or heritage. However, some players and managers have even been targeted by their own fans. The purpose of this report is to understand the current situation of racism within football, and look at what is begin done to help rid the game of it. With numerous governing bodies contained by sport, it is key to understanding what the main bodies choose to do to help endorse the fight against racism. It seems as though it is becoming more and more of a human rights issue, as players endure the direct racism from not only fans but club management teams.

Martin Luther King Essay Essays - Community Organizing, Free Essays

Martin Luther King Essay Essays - Community Organizing, Free Essays All people should be treated equally no matter what color skin they have, people deserve to have a chance of a bright future in a world that treats people equally. The importance of the I Have a Dream' speech by Rev. Dr. Martin Luther King, Jr. is that this speech portrayed the importance of equality between people and a man's passion of building a better world for the future generations. This essay shows that through passion and dedication you can accomplish anything. The I have a Dream' speech by Rev. Dr. Martin Luther King, Jr. changed the government into what we now live in. It changed so that segregation ended and people where equal. People weren't insulted by the color of their skin but on the personality of the person. It showed the government that all men had rights of life, liberty, and the pursuit of happiness. Rev. Dr. Martin Luther King, Jr. wanted to be granted civil rights for African Americans in a peaceful manner than through physical violence. Through this dedication and passion people are now treated with the same chance at success in life within a society who accepts them all equally. Rev. Dr. Martin Luther King, Jr.'s speech is important today because without those civil rights many people wouldn't have jobs because of the color of their skin. People wouldn't have the same opportunities as those with civil rights. African Americans wouldn't be able to contribute to society and help make the world a better place. We wouldn't have our first African American president. African Americans wouldn't be able to describe on character because of their skin color. African Americans wouldn't be able to be associated with white people. Everyone deserves to be treated with equal respect and rights. This is important in my life because we do have an African American president. African Americans have contributed to society and have been given the opportunity to make the world a better place. I have African American friends who are outstanding people who are dedicated hard workers. In the future I will be able to work with African Americans and be treated with equal rights. It proves that through the dedication of a few it can affect the future of many. Life is about rights and being treated equally. People are able to have the same opportunities as others and they show society that the government has done the right thin in providing them with civil rights in order to allow everyone a fair chance of success in life. In conclusion, the world is treating everyone with equal respect and dignity no matter what race or skin color they have society accepts everyone. No matter what people say it is within he rights of the government that all people should be treated equally and fairly between each other in a society who will accept them for who they are no matter what their skin color is. That is the importance of the I Have a Dream' Speech.

Free Essays on Thomas Kinkade - Geniune Or Poser

Thomas Kinkade, artist or businessman? This is the question that the three reviews by Karal Ann Marling, Brooke Cameron, and Mark Pohlad are basically arguing. Kinkade’s paintings and other works usually consist of a little house with the lights on. His work gives a sense of light and warmth at affordable prices. â€Å"His franchise earned more than $2 billion in 2000† (pg. 224). Marling is really supportive of Kinkade’s work. She argues that he is a family man because he puts his wife’s initials in his pictures. She also mentions that Kinkade takes after an artist by the name of Albert Bierstadt, who â€Å"bridges the gap between fine and popular art† (pg. 67). Cameron on the other hand also points out that his work is very soothing for the common person, but he gets more credit than he deserves. She also brings up that his pieces are not authentic, so why buy one? In her last line of the review she compares Kinkade to a â€Å"male Martha Stewart† (pg. 5), someone selling something that the average person can relate to and will buy. Pohlad brings together points that the two previous reviews argue, but his main point is the affordability. How many people do you know that can afford a Van Gogh or a Monet? I Know I can’t, but a Kinkade’s $1,500 painting is a quite a bit more within my grasp.... Free Essays on Thomas Kinkade - Geniune Or Poser Free Essays on Thomas Kinkade - Geniune Or Poser Thomas Kinkade, artist or businessman? This is the question that the three reviews by Karal Ann Marling, Brooke Cameron, and Mark Pohlad are basically arguing. Kinkade’s paintings and other works usually consist of a little house with the lights on. His work gives a sense of light and warmth at affordable prices. â€Å"His franchise earned more than $2 billion in 2000† (pg. 224). Marling is really supportive of Kinkade’s work. She argues that he is a family man because he puts his wife’s initials in his pictures. She also mentions that Kinkade takes after an artist by the name of Albert Bierstadt, who â€Å"bridges the gap between fine and popular art† (pg. 67). Cameron on the other hand also points out that his work is very soothing for the common person, but he gets more credit than he deserves. She also brings up that his pieces are not authentic, so why buy one? In her last line of the review she compares Kinkade to a â€Å"male Martha Stewart† (pg. 5), someone selling something that the average person can relate to and will buy. Pohlad brings together points that the two previous reviews argue, but his main point is the affordability. How many people do you know that can afford a Van Gogh or a Monet? I Know I can’t, but a Kinkade’s $1,500 painting is a quite a bit more within my grasp....

Texas Instruments essays

Texas Instruments essays Texas Instruments began its corporate life in 1930 as a company called Geophysical Service, which was a petroleum-exploration firm founded by a couple of eager men by the names of Dr. J. Clarence("Doc") Karcher and Eugene McDermott. They used seismology to find oil. It entered the defense electronics business during the 1940's and performed contracts for the Army and Navy Signal Corps. The company's name changed to Texas Instruments in 1951 and bought the rights to manufacture the germanium transistor in 1952 from a similar company by the name of Western Electronics for the astronomical price of twenty-five thousand dollars. Geophysical service soon became a subsidiary. This sale was ideal for this growing company. The transistor made possible the portable transistor radio and set the stage for the modern age of electronics. In 1960 another milestone was reached. The company had introduced its first commercially available integrated circuits (also generally known as semico nductors, or chips). In the early 1970's, the company developed a single-chip microprocessor, and introduced a four-ounce portable calculator, which was pretty bulky for that day and age, but was impressive for them at that time. Later in the decade the company began marketing an electronic watch that sold for about twenty dollars and a home computer. Up to that time Texas Instruments was doing very impressively, but the early 1980's was generally disappointing, as the company lost share in both semiconductor and consumer electronics markets. But in the late 1980's they introduced the world's first quantum effect transistor and they formed a joint venture with Acer Inc. to manufacture advanced semiconductors in Japan. With these new products and ventures in addition with a new campaign and a re-emphasis on its semiconductors, business brightened the company's prospects by the beginning of the 1990's. ...

Book Report on HEALTH AND HEALTH CARE 2010 The Forecast, The Challenge Term Paper

Book Report on HEALTH AND HEALTH CARE 2010 The Forecast, The Challenge - Term Paper Example IFTF enables organizations, companies, foundations, government agencies to make better, more informed decisions about the future, and it provides the foresight to create insights that lead to action. The book is a rare collection of thoughtful, insightful and robust forecasts covering almost all the crucial components of health and healthcare. This volume has been organized into logically sequenced eighteen chapters that cover a diverse set of topics ranging from historical trends to xenotransplantation. Each chapter includes self-explanatory and informative figures, graphs and tables. Aptly inserted sidebars in each chapter add another dimension to the text by facilitating a clear understanding of the chapter. I am of the opinion that this well researched and beautifully presented and an interesting book has been able to achieve its sole objective of providing the reader with â€Å"a description of critical factors that will influence health and health care in the first decade of the 21st century.† In the opening chapters, the book informs the reader about trends like widening economical divide, expanding and changing horizons w.r.t. nature of diseases from acute to chronic, mental and lifestyle oriented ones. It highlights the transforming demographic trends those are expected to have a far reaching effect on the evolving modalities of healthcare services delivery in America. The book also analyses the aspect of insurance in the changing scenario. Ever since the invention of the monaural stethoscope, technology’s role in medicine has been gradually increasing and today technology has secured a commanding position in almost all specialties of medicine. The book has discussed nine upcoming and promising technologies (and respective key barriers) those have the potential to â€Å"address intransigent issues and improve public health, extend our life