PepsiCo

Introduction PepsiCo is a leading manufacturer and seller of non-alcoholic beverages in the global beverage industry. The success of PepsiCo is mainly attributed to sound marketing strategies and product differentiation. Due to the high competition in the global and US beverage industry, PepsiCo must always review its marketing strategies and product portfolio. This will enable it to produce the right products and access new markets.Advertising We will write a custom case study sample on PepsiCo specifically for you for only $16.05 $11/page Learn More It is against this backdrop that this report seeks to analyze PepsiCo’s situation and future prospects in the alternative beverage industry. The report begins with the five forces and driving forces analysis. This will be followed by an evaluation of PepsiCo’s business model and financial performance. A SWOT analysis as well as an assessment of PepsiCo’s competitive strategy will, then, be conducted. Finally, recommendations on how PepsiCo can enhance its position and Future performance in the Industry will be presented. Porter’s Five Forces Analysis The Porter’s five forces analysis is a technique used to assess the competitive environment of a business. It particularly assists in gaining insights on the factors that affect competition in any given market. Competition in the beverages market can, thus, be explained as follows. Threat of Substitutes Currently, the alternative beverages are competing with a large number of substitutes. Such substitutes include carbonated soft drinks as well as juices. Additionally, the prices of alternative beverages are significantly higher than those for substitute drinks. For example, the prices for sports drinks as well as vitamin enhanced beverages were 50% to 70% higher than the prices of carbonated soft drinks of comparable sizes. Consequently, there is a possibility that customers shifted their preference from alternative beverages to carbonated soft drinks. Contrary to alternative beverages, substitute drinks such as juices are associated with low health risks. This differentiation is likely to make substitute drinks a better choice, especially, among customers who are concerned about their health. Thus, the threat posed by substitute products in the beverage industry is high.Advertising Looking for case study on business economics? Let's see if we can help you! Get your first paper with 15% OFF Learn More New Entrants The threat attributed to new entrants in the US and global alternative beverage industry is low due to the following reasons. First, the incumbent firms enjoy economies of scale. For example, Coca-Cola and PepsiCo have large production plants and operate in over 200 countries. Besides, the dominant firms command large market shares. PepsiCo, for instance, had 47.8% market share of alternative beverage market in US in 2009. Second, there is high product diff erentiation in the industry in order to counter competition. For instance, most companies focus on the taste, image and energy-boosting capabilities of their energy drinks in order to ensure customer loyalty. Third, joining the beverage industry requires a lot of financial capital. It is for this reason that small firms such as Hansen have had to outsource all their production and distribution activities. Fourth, the incumbents have a great control over the distribution channel. All small firms have contracted bottling companies and distributors such as Anheuser-Bosch to manufacture and distribute their products. Finally, the incumbents have high propriety knowledge in production and marketing. Dominants firms such as Coca-Cola have used patents to prevent new firms from accessing their production techniques. Power of Suppliers There are many suppliers of most of the production inputs in the beverage industry. Besides, there are many substitutes for production inputs such as packagi ng material. Product differentiation in the suppliers’ industry is high since the large number of suppliers leads to high competition. Additionally, the buyers (beverage manufacturers) are important to suppliers since they purchase large volumes of inputs. However, the buyers have low switching cost. For instance, a manufacturer can easily shift from one supplier to the other. This leads to the conclusion that the suppliers have a low bargaining power. Power of the Buyer There are many buyers in the beverage industry. The buyers have low switching costs, and can thus, obtain their supplies from different suppliers. The suppliers’ products are highly differentiated due to competition in their industry. Besides, the suppliers’ products are of great impotence since they determine the quality of the buyers’ end products. The threat of backward integration is, however, high since the dominant firms such as Coca-Cola and PepsiCo have the financial resources to purchase the input producing firms or to produce their own inputs. Thus, buyers have a moderate bargaining power.Advertising We will write a custom case study sample on PepsiCo specifically for you for only $16.05 $11/page Learn More Competitive Rivalry The threat attributed to competitive rivalry is very high in the beverage industry due to the following reasons. First, there are very many competitors, and this makes it difficult for each firm to expand its market share. Second, the beverage industry has a low growth rate. The industry’s growth rate is projected at 12% in five years (from 2009 to 2014). This is attributed to the fact that the industry is at its maturity stage. Besides, the 2008/2009 financial crisis negatively lowered demand in the industry. Third, distribution in the industry is associated with high fixed costs and storage costs. Finally, the products are highly differentiated. These conditions have contributed to high competit ion in the industry. Driving forces Analysis Driving forces are both internal and external factors that cause change in an organization. The main driving forces in alternative beverage industry include the following. Social The social factors include the behaviors of the consumers of various alternative beverages and the social events associated with the consumption of alternative beverages. Undesirable behaviors such as â€Å"mixing alcohol and energy drinks† led to disapproval of alternative beverages. This is because such behaviors can lead to over consumption of alcohol. The criticism had negative impacts on the demand for various alternative beverage brands. In response to customers’ need to simultaneously consume alcohol and energy drinks, companies such as Miller-Coors developed new products, alcohol energy drinks, which contain both alcohol and energy boosting capabilities. Demographic factors such as age and occupation also influenced the consumption of altern ative beverages. For instance, energy drinks are frequently consumed by teenage males, sports professionals, and manual laborers. Vitamin-enhanced beverages on the hand are highly purchased by adults. The marketing of most alternative beverages depend on social events. Most producers build their brand image by sponsoring sports activities, and music festivals. For instance, Red Bull sponsors sports such as athletics as a way of marketing its energy drinks. They also depend on celebrity endorsements to enhance the popularity of their products.Advertising Looking for case study on business economics? Let's see if we can help you! Get your first paper with 15% OFF Learn More Economy The economic performance of a country or region has significant effect on demand for alternative beverages. The financial crisis in US, coupled with the maturity of beverage industry led most producers to seek new markets. The rapid economic growth in emerging economies, especially in Asia, is expected to enhance demand for alternative beverages. Consequently, producers are exporting their products to overseas markets such as Australia. At the firm level, high cost of production has forced firms to seek efficient distribution techniques. For instance, small firms outsource various production and distribution activities in order to lower costs. Technology As competition intensify, firms focus on product differentiation on the basis of quality. This has been achieved through modern technology that facilitates research and development and efficiency in production. Modern communication technology enhances marketing in the industry by facilitating the design of clever adverts and appealing packaging. Communication technology also promotes synchronization of supply chain activities for firms that outsource various production and distribution activities. Political and Legal Factors Alternative beverages such as energy drinks and relaxation drinks have been associated with health risks such as heart arrhythmia. This has a negative impact on the production of these products. For instance, Miller-Coors had to eliminate the caffeine in its energy drink when attorney generals counseled for the ban of energy drinks with high caffeine content. Besides, health professionals are advising the public to avoid consuming relaxation drinks that contain kava. Competence Dominant firms such as Coca-Cola and PepsiCo owe their success to their core competencies. Both firms boast of a strong brand image. Besides, they have vast experience in production, and this enables them to access new markets. Finally, environmental factors such as weather patterns affect the consumption of alternative beverages. For instance, energy drinks are likely to be consumed on a hot day. PepsiCo’s Business Model PepsiCo directly produces and distributes its range of beverages in the markets it operates in. The customer segments served by PepsiCo include teenagers, adults, sports professionals and celebrities. The value proposition of the firm is characterized with a wide range of beverages and foodstuffs. The company sells both carbonated drinks such as sodas and alternative beverages such as energy drinks, vitamin enhanced drinks and sports drinks. In order to create value for its customers, each of the company’s drinks is tailored to meet specific needs for every customer segment. For instance, sports drinks are tailor made for sports personalities. PepsiCo offers its value proposition through different distribution channels. Its products are retailed by â€Å"supermarkets, supercenters, restaurants, and natural food shops†. The company also reaches its customers by sponsoring sports and music events as well as advertising its products. PepsiCo ensures customer loyalty by maintaining positive relationships with them. For instance, it ensures timely delivery of all alternative drinks to retailers such as convenience stores. The firm has the largest market share for alternative beverages in US, 47.8%. Thus, the sale of alternative beverages is the main revenue stream for PepsiCo. Other revenue streams include the sale of carbonated drinks and snacks. The key resources that support PepsiCo’s business model are a strong brand image, high product visibility (operates in over 200 countries) and a stable financial position. However, the firm incurs high sales costs (about 46% of its net income). Evaluation of PepsiCo’s Financial Performance The firm’s revenue in the 2007 financial year was $ 34,474 million. The revenue grew to $43,251 in 2008, reflecting a 9.6% growth. However, the revenue declined by 0.04% to 43,232 million in 2009. PepsiCo incurred sales costs amounting to $18,038 million in 2007, and $ 20351 million in 2008. This reflected a 12.8% increase in sales costs. In 2009, it managed to reduce its sales costs by 1.2% to $ 20,099 million. In 2007, PepsiCo made a profit of $ 7,182 million. The profits fell by 3.1% in 2008. Thus, it made $ 6,959 in operating profits. However, the firm managed to increase its profits by 15.6% in 2009. Thus, it made $8,044 in operating profits. The above information shows that PepsiCo increased its revenue by 9.6% in 2008. However, the increase in sales costs over the same period led to a 3.1% reduction in profits. The reduction in sales costs by 1.2% probably led to the 15.6% increase in profits. Overall, the company remained profitable between 2007 and 2009. We can conclude that it is financially stable. SWOT Analysis PepsiCo has the following strengths. It has a large market share that enables it to earn high revenues. Overall, PepsiCo is the â€Å"fo urth-largest producer of food and beverages†. It also has the largest market share of alternative beverages in US. PepsiCo has a well established brand image. It sells some of the most popular drinks such as Lay’s and Tostito. The brand image is a core competence that enables it to venture into a variety of markets, thereby increasing sells. Finally, PepsiCo has a stable financial position. Consequently, it can easily finance its expansion programs. The main weakness of PepsiCo is its inability to outperform Coca-Cola (its main competitor) in the manufacture and sell of carbonated soft drinks. Since carbonated soft drinks and alternative beverages are substitutes, PepsiCo might lose its overall market share if there is a major shift in preference in favor of carbonated soft drinks. PepsiCo has the following opportunities in the industry. The threat attributed to new entrants is low in the industry. This means that competition is not likely to increase as a result of new firms joining the industry. Thus, PepsiCo has the opportunity to increase its production in order to meet future increases in demand. The low bargaining power of suppliers in the industry is also an opportunity for PepsiCo. In particular, it has the opportunity to bargain for cheap supplies. Besides, it has the opportunity to obtain high quality inputs as suppliers compete among themselves. The rapid growth in purchasing power in emerging economies is an opportunity for PepsiCo to expand by joining the emerging markets. The threats facing PepsiCo include the following. The threat attributed to substitute products is likely to constrain PepsiCo’s ability to increase the prices of its products. This will have a negative impact on revenue and profits. Besides, it can lead to significant loss of market share. The threat attributed to competitive rivalry is likely to reduce PepsiCo’s revenue and ability to expand. This is because sales and marketing costs rise as firms att empt to counter competition through advertising and differentiation. The alternative beverage industry in US where PepsiCo has the largest market share is at its maturity stage. Besides, the economic down turn in US has shifted demand away from alternative beverages. Thus, PepsiCo’s revenue streams from the US market are likely to reduce. PepsiCo’s Competition Strategy As a dominant firm in the beverage industry, PepsiCo is pursuing market leadership strategies. The company has focused on market expansion programs by joining new markets. Additionally, the firm focuses on new product development in order to find new market segments. PepsiCo is also keen in defending its large market share in various regions. This has been achieved through innovation that helps to improve its marketing mix. Such innovative activities involves promotion blitz that engage celebrities and the youth in order to ensure customer loyalty. The firm’s products are constantly improved and d ifferentiated on the basis of quality, tastes and visibility. The expansion strategy is likely to help PepsiCo to maintain its dominant position in the industry, especially, in the alternative beverage market. However, in addition to being defensive of its market share, PepsiCo needs to be offensive. As more firms compete for the alternative beverage market share, PepsiCo should also aim at increasing its market share for alternative beverages as well as carbonated soft drinks. Recommendations Given the analysis of PepsiCo’s competitive and internal environment, the following recommendations can be considered by its management in order to improve its competitiveness. Cost Leadership Strategy In order to pursue this strategy, PepsiCo must aim at producing at the lowest cost in the industry. Thus, it can sell its products at the prevailing prices, thereby making higher profits than its competitors. In order to enhance market penetration for its new products, PepsiCo can reduce its prices below the prevailing prices. This will lead to an increase in market share for the new products. The cost leadership strategy can be implemented by improving production efficiency which reduces production costs. The firm can also focus on optimal outsourcing in order to avoid unnecessary costs. PepsiCo can gain access to cheap and reliable supply of raw materials through backward integration. PepsiCo has the ability to pursue cost leadership strategy since it has the financial resources to invest in production assets. Such an investment will be an entry barrier to the small firms that lack adequate financial resources. PepsiCo also has the experience and expertise in manufacturing high quality products. Additionally, its efficient distribution channel will enable it to reduce sales costs. The benefits of this strategy are as follows. First, the ability to reduce prices will act as an entry barrier to firms that intend to join the alternative beverage industry where PepsiC o has the largest market share. Second, PepsiCo can use low prices to counter the threat attributed to substitute products. Finally, competing on the basis of price will enable PepsiCo to counter the threat attributed to competitive rivalry in the industry. Differentiation Strategy This involves producing products that â€Å"offer unique attributes that are valued by customers†. Currently, every firm in the industry is focusing on product differentiation, thus, PepsiCo can only defend its market share by doing the same. In this context, the firm must continue to improve its existing range of products. This will enhance customer loyalty. Besides, it must produce new products that meet emerging needs of the market. PepsiCo has the ability to pursue the differentiation strategy since it has the financial resources to undertake research and development. The research and development will help in developing high quality products. Additionally, it has a reputation for producing high quality products through innovation. The benefits of differentiation strategy include the following. Customer loyalty will act as an entry barrier if potential entrants can not attract PepsiCo’s customers. The customers will be attached to the differentiating characteristics, and this helps in countering the threat posed by substitutes. Finally, brand loyalty will help in countering competition. Conclusion PepsiCo is a leading manufacturer and seller of various beverages and foodstuffs. The analysis of the competitive environment indicates that suppliers have low bargaining power. The substitute products and competitive rivalry pose high threats in the industry. However, new entrants have low threats for the incumbents. These forces present both threats and opportunities to PepsiCo as discussed above. The main driving forces in the industry include technology, social, core competence, political/legal and economic forces. PepsiCo’s main strengths are its brand image an d large market share. Its main weakness is its inability to lead in the carbonated soft drink segment. In order to improve its competitiveness, the firm can pursue both cost leadership and differentiation strategies. References Aguirre, I. (2004). Product Differentiation with Customer Arbitrage. 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This case study on PepsiCo was written and submitted by user Emilia Z. 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. PepsiCo

How to Self-Publish a Graphic Novel

How to Self-Publish a Graphic Novel How to Self-Publish a Graphic Novel Crowdfunding the graphic novel on KickstarterKickstarter is a fantastic platform but it's an incredible amount of work. Aside from the lengthy setup, I spent 50 days busting my backside to reach my funding limit, broadcasting tweets, securing guest blogs, sending emails and generally pestering people to help me raise the money. If I could convey any advice on crowdfunding it's not to underestimate the effort it takes to reach your goal.With the help of 166 backers, I was lucky enough to raise  £5,617 for The Written Graphic Novel. As you can imagine I was incredibly pleased, even though the real work was now to begin.The first step was to get the artwork done. This was down to Mike Shipley, my fantastic artist. With the help of a dozen mood-boards, we spent several months plotting out how the artwork could sit alongside the story. After storyboarding each page, all 130 of them, Mike got stuck in.A year and five months after we launched the project, we hit the preparation stage. Eve n though I'm an expert in self-publishing and tour the UK teaching fellow authors how to self-publish books, publishing a graphic novel was new territory for me. As I do all the typesetting for my print books, there was a steep learning curve, consisting of ink densities, DPIs, CMYK versus RGB, PDF compression, and all the other aspects that come with moving from black and white print-ready files to full-color printing. However, it was a rewarding process. It taught me a lot, and I was especially glad for the experience as I was able to pass the knowledge onto the authors that I help self-publish.Formatting and self-publishingNow publishing the print version, even though it took a bit of back and forth with  Ingram Spark, a very helpful and major print-on-demand company, was relatively straight forward. It took a few months to process but by December the paperback was out across the globe in a range of stores. It was now time to turn my attention to creating the eBook version â₠¬â€œ the more technical of the two.With eBook formatting, there are a few more aspects to consider compared to typesetting. There are two major eBook formats, multiple types of eReaders, screen sizes and even orientations to bear in mind. I always recommend working with a professional when it comes to the technical job of formatting. The reading experience is very important indeed, and you want to get it spot on for your esteemed readers. That's why I took my own advice and turned to Reedsy to find myself the perfect technical formatter for the job.You can find The Written Graphic Novel and the rest of Ben Galley’s fantasy books at www.bengalley.com, His is self-publishing advice service can be found at www.shelfhelp.info.  Ben can be found being loquacious and attempting to be witty on Twitter (@BenGalley) or Facebook (/BenGalleyAuthor).Have you ever thought about  adapting your novel into a graphic novel? If no, what's stopping you? Let us know your thoughts, or any que stions for Ben, in the comments below!

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In Life in Schools: An Introduction to Critical Pedagogy in the Social Foundations of Education, McLaren points out that critical pedagogy aims at investigating, questioning and changing the relationship among different factors in the learning experience. These factors include classroom teaching, the structure of the school, and the social relations with the community. This imposes a great task on the critical pedagogue as he has to take into account a wide range of social and educational variables in his work (26-28). Critical pedagogy has its roots in Paulo Freire who is generally considered to be the inaugural philosopher of critical pedagogy (McLaren, Paulo 1). Although at first Freire dedicated his efforts to issues related to literacy in Brazil, his philosophy expanded gradually to embrace a cornucopia of social and educational issues that have been the object of criticism. In Pedagogy of Freedom: Ethics, Democracy, and Civic Courage, Freire pointed out that what he called for was not merely a pedagogical method; rather, it was a strategy of living within the educational system (67). McLaren observes that the bottom-line of Freires pedagogy is to establish a non-hegemonic approach that is based on dialogue and interaction (McLaren, Paulo 2). This clearly shows the political dimensions of Freires philosophy. Freire actually stressed the importance of incorporating social and political critiques in the curriculum. This explains why his approach promotes a liberatory form of education that emphasizes emancipation and rejects all forms of oppression and domestication. In The Politics of Education, Freire maintains that the learning process should take into consideration two essential dimensions. The first is the context of authentic dialogue between learners and educators (49). The dialogue will empower students to move toward becoming knowing subjects and they will develop a relationship with the teacher in which one knowing subject [is] face to face with other knowing subjects (49). For Freire, by employing authentic dialogue in the teaching process, education becomes pedagogy of knowing rather than an experience of narration sickness (Freire, Oppressed 57). However, Freire warns that the dialogic process should not be reduced to simple to-and-fro questions that may also become tedious and sterile. Instead, there should be a focus on creating interaction between students and teachers in problematizing knowledge. In this regard, it is the responsibility of the teacher to inspire students to move forward within this critical practice (Freire, Freedom 80). The second dimension that should be considered in the learning process is the social realities in which students live. Freire states that authentic thinking, thinking that is concerned about the world is concerned with reality, and does not take place in ivory tower isolation, but only in communication (Freire, Oppressed 64). This suggests that earning should be connected to the realities of students lives. Otherwise, by ignoring these realities, educators will be creating divisions that make difficult the construction of our ideals of change and transformation (Freire, Freedom 55). A very influential concept in Freires philosophy is that of praxis. Freires praxis, which delineates critical reflection and action, entails the application of educational practices and philosophies to create a better educational experience. To this end, students should be viewed as active participants in the teaching process and in the formulation of teaching methods. They are engaged in what Simon calls a transformative critique of their everyday lives (Simon, Teaching 60). The teachers role here resides in encouraging students to get involved in reflection on their worlds so as to assist them in engaging in critical consciousness. For Freire, the development of critical consciousness in the student can be attained by means of implementing what he called the problem-posing model of education. Freire proposed this model as a counterpart to the banking system of education dominating the educational institutions. He asserts that the banking system fosters domination and oppression, whereas the problem-posing mode promotes liberation and democracy. He goes on to claim that whereas banking education anesthetizes and inhibits creative power, problem-posing education involves a constant unveiling of reality. The former attempts to maintain the submersion of consciousness; the latter strives for the emergence of consciousness and critical intervention in reality. (Freire Oppressed 68). Freires philosophy of education was adopted and modified by various writers. The most prominent figure in this aspect is Ira Shor, who was mainly influenced by Freire. In his Critical Teaching and Everyday Life, Shor criticizes the institutionalized modes of education which involve undemocratic approaches. He demonstrates that these traditional systems have restricted students from contributing to the learning processes. He calls for implementing learning activities that are democratic in nature. These activities are set against the notions of education that students have from their previous experiences within the traditional pedagogical system. The democratic methods of teaching would change the role of students from passive to active critical subjects in which they become active participants in their own learning (111-113). Shor also pointed out some of the limitations of Freires assumptions. Examining the applicability of the Freirean philosophy, he stressed the difficulties involved in implementing the principles of this philosophy within the classroom setting. In his When Students Have Power, he strongly argues that despite the benefits gained from the implementation of the assumptions of critical pedagogy; these assumptions do not go smoothly when turned into practice in the context of classroom environment (56). However, Freire responded to this claim when he stressed the fact that his educational philosophy was not merely a collection of strategies that could be implemented in all educational environments. Rather, different educational practices should be adapted depending on each individual context. Freire acknowledged that pedagogy is influenced by ideology and since ideologies vary a lot, the existence of a single philosophy of critical pedagogy is not practical. Hence, one cannot speak of pedagogy but must speak instead of pedagogies which respond to particular necessities, interests and conditions (Gaudiano and de Alba 128). The challenges of reaching a definite conception of critical pedagogy brought about different approaches to the philosophy by many writers. bell hooks, for example, supports Freire in promoting the link between theory and practice in order for the student to be the center of the teaching process. However, she does not employ Freires concept of critical pedagogy. Rather, she has introduced what she calls engaged pedagogy. She defines it as a system that combines anticolonial, critical, and feminist pedagogies à ¢Ã¢â€š ¬Ã‚ ¦ for interrogating biases in curricula that reinscribe systems of domination à ¢Ã¢â€š ¬Ã‚ ¦ while simultaneously providing new ways to teach diverse groups of students (qtd. in Florence 10). A central feature of this model is the repudiation of the use of sophisticated language; a key feature of traditional educational methods that creates barriers between students and teachers. Roger Simon has introduced another significant approach to critical pedagogy which he calls pedagogy of possibility. In his Empowerment as a Pedagogy of Possibility Simon contends that proposing pedagogy is also proposing a political ideology. Hence, this model of pedagogy aims at enabling a particular moral project, a particular not yet of how we might live our lives together (372). He stresses the fact that such a pedagogy will require forms of teaching and learning linked to the goal of educating students to take risks, to struggle with ongoing relations of power, to critically appropriate forms of knowledge that exist outside their immediate experience, and to envisage versions of a world that is not yet in order to be able to alter the grounds upon which life is lived (375). Like Freire, Simon stresses the importance of not looking at his ideas as mere abstractions. Rather, they should be put into practice in all educational environments. Teachers who would implement the principles of the pedagogy of possibility must not expect a guideline for techniques to be adopted, but rather approach such a task strategically, locally and contextually formulating practice within an integrated moral and epistemological stance (Simon, Teaching 58). This will lead to a possibility for creating counterdiscursive activity that attempts to provoke a process through which people might engage in a transformative critique of their everyday lives (60). The complexities inherent in critical pedagogy have given rise to many critiques of its principles and assumptions. The scope of the criticism directed against critical pedagogy is so vast that it includes critiques from disciplines such as feminism, and postmodernism. It is of high importance to shed light on some these critiques directed against critical pedagogy in order to identify the potential challenges in implementing its practices in classroom environment. The first critique to be considered is that which comes from the very nature of critical pedagogy itself. Critical pedagogy inherently requires a constant investigation of its principles and practices. In this aspect, Giroux and McLaren contend that many current trends in critical pedagogy are embedded in the endemic weaknesses of a theoretical project overly concerned with developing a language of critique. Critical pedagogy is steeped in a posture of moral indignation toward the injustices reproduced in American public schools. Unfortunately, this one-sided emphasis on critique is matched by the lack of theoretical and pragmatic discourse upon which to ground its own vision of society and schooling and to shape the direction of a critical praxis (32). In her The Struggle for Pedagogies: Critical and Feminist Discourses as Regimes of Truth, Jennifer Gores critique of critical pedagogy is based on her contention that there are two distinct versions within critical pedagogy; she identifies these versions according the prominent figures who most contributed to the philosophy of each strand. The first version contributes to what she calls pedagogical practice. She suggests that Freire and Shor represent this strand of critical pedagogy which offers concrete suggestions and examples taken from their own pedagogical practice, and which is intended to help other educators (40). Gores criticism is directed against the other approach which she calls pedagogical project. This approach is represented in the contributions of many significant pedagogues, mainly Giroux and McLaren. Gore claims that their approach relies heavily on an abstract political vision and should not be called critical pedagogy, but critical educational theory (42). She goes on to argue that the major shortcoming of such an approach resides in its failure to delineate a set of practices for classroom teaching. As a result, their pedagogy might be seen to restrict its audience to those readers who have the time, energy, or inclination to struggle with it à ¢Ã¢â€š ¬Ã‚ ¦ and, in so limiting its audience, it subsequently limits its political potential (38). Essentially, Gores criticizes the fact that such critical pedagogues tend to focus on abstract theories that lack the potential for implementation. As an example, Gore cites the concept of empowerment, which is a key principle in critical pedagogy. Within the pedagogical project model, the concept of empowerment has been confined to extreme abstraction that forces teachers to be the agents of empowerment, without providing much in the way of tangible guidance for that work (Gore, What 66). Hence Gore calls for creating guidance for teachers so that principles of critical pedagogy can be translated into reality. However, Gore does not call for creating recipes for educational practices. Rather, she contends that theorists of critical pedagogy should take into consideration the context of the educational process instead of merely adhering to a unified theoretical background (Gore, What 67). As mentioned above, Freire himself rejected an essentialist view of critical pedagogy and called on teachers to adapt the learning process to the context of students experiences. In this regard, a great responsibility lies on teachers in determining the methodologies appropriate for each particular context. Similarly, Elizabeth Ellsworth employs a feminist perspective to refute any essentialist interpretation of critical pedagogy. She goes on to claim that even the term critical is a repressive myth[s] that perpetuate[s] relations of domination and hides the actual political agendas à ¢Ã¢â€š ¬Ã‚ ¦ namely antiracism, antisexism, anti-elitism, anti-heterosexism, anti-ableism, anti-classism, and anti-neoconservatism (93). She also believes that theorists of critical pedagogy have failed to launch any meaningful analysis of or program for reformulating the institutionalized power imbalances between themselves and their students, or of the essentially paternalistic project of education itself (98). Moreover, Ellsworth develops a deconstructionist critique of critical pedagogues. She claims that these pedagogues are implicated in the very structures they are trying to change (101). She criticizes the fact that much of the literature of critical pedagogy is the work of the dominant white middle class men. She goes on to argue that a relation between teacher/student becomes voyeuristic when the voice of the pedagogue himself goes unexamined (104). In his Elements of a Post-liberal Theory of Education, Bowers basic criticism resides in his claim that, in a way, critical pedagogy enforces the assumptions and values of Western metaphysics. Although he promoted the contributions of Freire and his followers, Bowers believes that Freires model emphasizes the modernist way of thinking, and thus it reinforces Western values and principles. For Bowers, all Freires pedagogy is based on Western assumptions about man, freedom, progress, and the authority of the rational process (127). He claims that the problem with Freires position is not that he advocates critical reflection but that he makes it the only legitimate source of knowledge and authority (129). Although Freires emphasis on dialogue as a basic component of the educational process has been praised as a democratic strategy, Bowers criticizes the very notion of using dialogue as a tool for emancipation. He contends that relying on dialogue in this aspect shifts the locus of authority from that of community and tradition to the individual who unifies thought and action in a new praxis (129). This focus on the individual on the expense of other collective concerns has lead to the failure of critical pedagogy in addressing issues related to ecology and the nature of the world. As he puts it, The problems of inequality and restricted individual empowerment are not nearly as important as the cultural roots of our alienation from nature. Regardless of how our agenda for social reform is framed, the bottom line has to do with reversing the global ecological deterioration we are now witnessing (159). A very important critique of critical pedagogy that should be highlighted here is that which comes from a postmodern perspective. In their Dialogue across Difference: Continuing the Conversation, Burbules and Rice explore the postmodern critique of critical pedagogy. The authors start their argument by suggesting that there are two versions of postmodernism that hold different positions relative to modernism itself (397). They call these two versions postmodernism and antimodernism. The authors suggest that a basic characteristic of postmodernism is that it goes beyond the norm but at the same time accepts the basic significance of the tradition it proposes to go beyond (397). They cite Giroux and McLaren as examples on postmodernist critics who relish some key democratic assumptions of modernism and yet go beyond them. Antimodernism, on the other hand, defines itself as the antithesis of modernism and is characterized by a strong antipathy to the language, issues, and values of modernism (398). The authors criticize this strand and assert that having deconstructed all metanarratives and radically relativized all possible values, antimodernism is left with no clear way of justifying any alternatives (398). The different positions of postmodernism and antimodernism account for the dissenting views related to the relationship between critical pedagogy and postmodernism. In this regard, some writers strongly believe that critical pedagogy is far from incorporating the premises of postmodernism. In Reflective Teaching in the Postmodern World: A Manifesto for Education in Postmodernity, Parker holds the view that many critical educational practices involve some modernist assumptions and fail to account for a genuine understanding of the process of knowledge construction from a postmodern perspective (16). Similarly, there are other feminist and postmodernist writers who assert that some strands of critical pedagogy do not address such issues which are of high importance in the field. In her Freire and a Feminist Pedagogy of Difference, Weiler explores the conflict she perceives between the modernist orientations of critical pedagogy and postmodernism. As a feminist writer arguing from a postmodern perspective, she claims that her goal is to retain the vision of social justice and transformation that underlies liberatory pedagogies (450). She suggests that the universal goals of liberation do not directly analyze the contradictions between conflicting oppressed groups or the ways in which a single individual can experience oppression in one sphere while being privileged or oppressive in another (450). Accordingly, Weiler believes that the theory that calls for the existence of universal experience of oppression does not take into account the specific contexts of the classroom experience. Hence the focal point of her argument resides in redefining the collective experience in the context of historically defined struggles (Weiler 451). In this regard, Weiler claims that Freire ignored the existence of diverse experience of oppression; hence she calls for a more situated theory of oppression and subjectivity, and for the need to consider the contradictions of such universal claims of truth or process (456). Weiler argues for a feminist-postmodern approach to confront the deficits in Freires philosophy of pedagogy. In this regard, she delineates three major issues where this process can be implemented. She names these as the role and authority of the teacher, the claims for knowledge and truth in personal experience, and the question of difference. Weiler concludes by asserting that the existence of different approaches in this arena does not necessitate abandonment of the goals of social justice and empowerment, but it does make clear the need to recognize contingent and situated claims and to acknowledge our own histories and selves in process (470). On the other side of the spectrum, there are many writers who strongly believe that critical pedagogy strongly incorporates some aspects of postmodernism. In Critical Crosscurrents in Education, Collins sheds light on this link between critical pedagogy and postmodernism as he suggests that, like critical pedagogy, postmodernist critical discourse is about the struggles for power to be heard about the empowerment of other voices' (76). In the same vein, Pinar et al. suggest that there is a possibility for developing a strand of pedagogy that engages in some postmodern principles. This version of pedagogy goes beyond the issues of oppression and suffering that are merely viewed from a class- struggle perspective (305). Other writers share the same view and contend that the philosophy of Freire and other critical pedagogues does incorporate some postmodern dimensions. Most of these writers approach this issue through dividing Freires writing into different phases, stressing that the postmodern orientations appear in his later work. Peters, for example, suggests that there are some postmodern ideas that can be clearly seen in Freires later work. These ideas include Freires emphasis on textuality, subjectivity, experience and culture in addition to his own interpretation of oppression and power (117). Similar to Peters, Roberts asserts that in order to locate the modernist inclinations in Freires writing we should look at Freires work as a whole, and not to focus on his writings during the first stage of his work. Roberts contends that Freire did promote some postmodern techniques in confronting all forms of oppression. He also highlights Freires confrontation with postmodern critics, especially in his later writing. Roberts examination of this issue concluded in his contention that Freire argues for what he called progressive postmodernism. Freire has stressed the fact that educators should challenge modern ways of thinking through becoming more tolerant, open and forthright, critical, curious, and humble (112). Clearly, the above argument proves that any attempt to come up with a clear-cut definition of critical pedagogy is utterly challenging. As mentioned above, there are multiple approaches to critical pedagogy, and there are also variables from other disciplines that are easily accommodated in this literature. All this results in creating critical pedagogies rather than one definite and universally- accepted form of critical pedagogy. These critical pedagogies are always involved in a constant process of redefinition and change, thus imposing great challenge on pedagogues in this regard. Despite these variations and challenges, teachers are always urged to go beyond the mere theoretical background of critical pedagogy. The process of theorizing without action creates no change and goes against the objectives of critical pedagogy. Teachers must promote an integrated approach of theory and practice, or what Freire called praxis. In other words, they should seriously consider the potential for implementing the premises of critical pedagogy in the teaching process. This implementation should go beyond the mere adherence to an essentialist view of a critical pedagogical methodology. Teachers should attempt, to the best of their abilities, to locate the teaching process within the realities of students lives. They should take into account the various variables, realities and experiences pertinent to students lives. Hence, they should adapt their techniques according to the specific variables pertinent to the context in which they work. The critique directed against critical pedagogy maximizes the need for this constant action on the part of teachers. In addition to adapting their educational tools to the classroom context, teachers are exhorted to encourage the involvement and empowerment of the students. Without putting the assumptions, principles and paradigms of critical pedagogy into practice, teachers run the risk of going within the traditional mainstream models of education. As Bahruth and Steiner beautifully put it: in our profession we have two choices; we can succumb to the mainstream and become programmed toward deskilling our intellect, or we can become critical pedagogues and liberate ourselves and those who choose to join in the dialogue (143).

Biometrics :: Biotechnology Science Essays

Biometrics Biometrics is a new term for many, but it is not a new idea. The idea of Biometrics first began with finger print analysis. Today, Biometrics has expanded to not only your fingerprints but also ear, face, facial thermogram, hand vein, hand geometry, iris, retina, signature and voice analysis. Technology has gone from science fiction to reality. This paper will include a brief description of each of the types of Biometrics and who is using them. The answer to "Who is using Biometrics?" may surprise you. In the United States over 150 schools are using a Biometrics system. This system allows the children to pay for cafeteria lunches. Over 200,000 students are participating in the Fingerprint Biometric system. The average system will cost any where from $4,000 to $10,000 to implement. How does it save you money? The answer is simply, you no longer need cashiers. All you need is a monitor. There is no longer cash to be accounted for, and children no longer have to bring money to school. Parents don’t have to worry how the money is being spent. The Fingerprint system is easy and results in quicker lines. Some major concerns for the parents are; 1.) How does the Fingerprint technology work? 2.) Can this technology be used in the police department? 3.) What about privacy issues? The technology being used in our school cannot be used in law enforcement. The fingerprint of your index finger is scanned, then transformed into a twenty-seven point grid, and a mathematical algorithm is the result. This is what the computer matches upnot your actual fingerprint. Ear Prints have had success for the Police in the United Kingdom. They have been using this technology to find missing persons and to identify unknown bodies. Ear prints are generally accepted as being unique, still it is hard to get a conviction if an ear print was left at the seen of a crime. Even though each ear is unique with its contour and lines; it has not been proven beyond a reasonable doubt that the ear print itself left behind is unique. There are fears of this new technology, because of its possible misuse and its accuracy. One of the greatest fears is that our justice system will go from innocent until proven guilty to guilty until proven innocent. This technology will bring great benefits until it fails, and then a tremendous amount of harm to even those who benefit from the technology.

Investigation of Enthalpy Change When Mg is added to HCl Essay

Research Question: How is the enthalpy change of the reaction between Mg and HCl affected when different amounts of Mg are added to a constant amount of HCl? Variables: Independent: Mg Dependent: Temperature Control: HCl Controlling Variables I will use three different masses of Mg: 0.02g  ± 0.001g, 0.03g  ± 0.001g, 0.04g  ± 0.001g I will measure the temperature using a colorimeter made from a foam cup, a lid, and a thermometer I will keep HCl at a constant volume of 10mL of 1M HCl Procedure: Step 1: Measure out 10mL of 1M HCl Step 2: Pour HCl into foam cup and place lid on cup Step 3: Measure the initial temperature and record data Step 4: Add in 0.02g of Mg into cup and measure the finial temperature Step 5: Calculate change in temperature by subtracting the initial temperature from the finial temperature Step 6: Repeat steps 1-5 8 more times for a total of 9 trails changing the mass of Mg in step 4 every 3 trails from 0.02g  ± 0.001g to 0.03g  ± 0.001g to 0.04g  ± 0.001g. Conclusion and Evaluation The results depicted a small correlation between the enthalpy change in the reaction between Mg and HCl when different amounts of Mg are added to a constant amount of HCl. The average enthalpy change of the different masses of Mg are not consistently changing. When the amount of Mg shifts from 0.02g  ± 0.001g to 0.03g  ± 0.001g the average enthalpy changes from 453.27 kJ/mol to 406.77 kJ/mol but when it shifts form 0.03g  ± 0.001g to 0.04g  ± 0.001g the average enthalpy changes from 406.77 kJ/mol to 418.4 kJ/mol. Now the answer to the question -How is the enthalpy change of the reaction between Mg and HCl affected when different amounts of Mg are added to a constant amount of HCl? – Is there is an effect to the enthalpy change when different amounts of Mg are added but it is irregular and the change in the enthalpy isn’t steady in its rise or decline. The experiment was done using different foam cups and a calorimeter and the amount of time that the chemicals temperatures were recorded were different. If I was to improve this experiment I would use the same kind of foam cups and lids for each trial and I would also measure the temperature for each chemical under a specific time limit which would be the same for each trial. Investigation of Enthalpy Change When Mg is added to HCl

Pediatric Dengue Shock Syndrome Essay Example

Pediatric Dengue Shock Syndrome Essay Example Pediatric Dengue Shock Syndrome Essay Pediatric Dengue Shock Syndrome Essay Michelle de Vera,1 M. D. , and Marissa M. Alejandria,2 M. D. ABSTRACT Background: The cornerstone of therapy for dengue shock syndrome (DSS) remains to be the prompt and aggressive restoration of circulating plasma volume. Two common types of intravenous uids currently used in DSS are crystalloids and colloids. The debate is ongoing on whether one is superior to the other in critically ill patients. Objective: This systematic review aims to compare the therapeutic effects of colloids versus crystalloids in reducing the recurrence of shock, the requirement for rescue uids, the need for diuretics, the total volume of intravenous uids given, the hematocrit level and pulse rates, and mortality rates of children with DSS. Search strategy: We searched Medline 1966 to August 2008, the Cochrane Controlled Trials Register (The Cochrane Library Issue 1, 2008), and the Philippines Herdin database 1964 to 2008. Local journals were handsearched and reference lists were examined. Researchers and experts in the eld were contacted for unpublished or ongoing trials. Selection criteria: The studies included were randomized controlled trials comparing colloids versus crystalloids in children less than 18 years with a diagnosis of DSS. Data collection and analysis: Two reviewers independently did trial selection and assessment of methodologic quality using the Cochrane Infectious Diseases Group criteria. Two reviewers independently extracted the data and analyzed it using Review Manager Version 5. Results: Of eight studies initially reviewed, four studies ful lled the selection criteria (N=694, colloids=410, crystalloids=284). Colloids and crystalloids did not differ signi cantly in decreasing the risk for recurrence of shock (RR 0. 92, 95% CI 0. 62 to 1. 38), the need for rescue uids (RR 0. 90, 95% CI 0. 70 to 1. 16), total volume of intravenous uids given (WMD 0. 80, 95% CI -1. 68 to 3. 28) and the need for diuretics (RR=1. 17, 95% CI 0. 84 to 1. 64). However, there were signi cant improvements from baseline in the hematocrit levels (WMD -3. 37, 95% CI -5. 94 to -0. 0) and pulse rates (WMD -3. 37, 95% CI -5. 94 to -0. 8) of patients who were given colloids. Tests for heterogeneity were not signi cant. Allergic type reactions were seen in patients given colloids. One child died in the colloid group. Conclusion: Colloids decreased the hematocrit and pulse rates of children with DSS after the rst two hours of uid resuscitation. However, no signi cant advantage was found over cr ystalloids in reducing the recurrence of shock, the need for rescue colloids, the total amount of uids, the need for diuretics, and in reducing mortality. KEYWORDS: Meta-analysis, Crystalloids, Colloids, Pediatric, Dengue shock syndrome Department of Pediatrics, The Medical City Department of Clinical Epidemiology, UP College of Medicine 1 2 *Best Paper, The Medical City Interdepartmental Research Forum, 2008 14 Philippine Journal of Microbiology and Infectious Diseases Vol. 39, Issue 1, January-June 2010 Colloids of lifesaving F luid resuscitation is oneshock thecritically ill cornerstones in managing in patients. Physicians have an array of intravenous uids to choose from, however, the debate continues on which type of uid would be most bene cial. One condition that would bene t most from smart uid choice is dengue shock syndrome (DSS). DSS is the most serious manifestation of dengue hemorrhagic fever (DHF). The burden of disease is greatest in Asia, where in many countries dengue is a leading cause of pediatric hospitalization. An estimated 500,000 patients with severe dengue require hospitalization each year, a large proportion of which are children. At least 2. 5% of patients die, although case fatality could be twice as high. 1 The major pathophysiological event seen in DSS is the acute increase in vascular permeability leading to the loss of plasma from the vascular compartment. Thus, the key to its management is the rapid restoration of the circulating intravenous blood volume. Two common types of intravenous uids currently used in DSS are crystalloids and colloids. Crystalloids are uids based on a solution of sterile water incorporated with electrolytes that are formulated to be hypertonic, hypotonic, or isotonic in com parison to the human plasma. The most common formulations include 0. 9% isotonic saline which is designed to approximate closely the human plasma, and lactated Ringer’s solution, almost similar to isotonic saline, but with the addition of lactate. Colloidal uids are also water- and electrolytecontaining solutions, but with the addition of a substance that does not easily diffuse through a semipermeable membrane owing to its high molecular weight. Albumin preparations contain human serum albumin, the largest component of colloid osmotic pressure in the human blood. The hetastarches, which are 6% hetastarch and 10% pentastarch, are derived from a polysaccharide that is incorporated in a uid with different molecular weights. Dextran solutions use synthetically derived dextran proteins. Gelatin solutions have true gelatin component designed to be biologically compatible. 3 The current guidelines in the management of DSS include administration of crystalloid intravenous uids at a rate of 10-20mL/kg over an hour upon presentation of unstable vital signs or manifestations of shock. Shifting to colloidal solution is warranted if there is evidence of hemoconcentration despite administration of about 1 liter of initial intravenous uids, as shown in Appendix 1. Once improvement is seen, colloids should be shifted back to crystalloids. The increased vascular permeability in DSS, combined with the capability of crystalloid uids to seep through easily, predisposes a patient to receive massive volumes until hemodynamic stability is achieved. This led to the belief that colloids, with their higher molecular weight and ability to maintain or improve the colloid osmotic pressure, will require less amount to achieve improvement, and can thus be a better alternative to crystalloids during the early resuscitative phase in DSS. The studies that have investigated the bene ts of colloids over crystalloids in patients with shock are limited. The large, multi-center, double-blind, randomized controlled trial Saline vs Albumin Fluid Evaluation conducted in 2004 compared the colloid albumin and the crystalloid isotonic saline for uid resuscitation in 6,997 intensive care unit patients. In the said trial, albumin and saline were comparable in terms of 28-day all cause mortality. 4 Likewise, a systematic review of the use of colloids and crystalloids for uid resuscitation in critically ill patients found no evidence that colloids, compared with crystalloids, reduced the risk of dying. Despite the increasing numbers of patients with DSS who are mostly children, there are only a few studies that compared the use of colloids and crystalloids in these patients. 6-9 OBJECTIVES The purpose of this systematic review is to synthesize the available data from clinical trials comparing colloids and crystalloids in resuscitating children with DSS. It aims to estimate the effects of colloids compared to crystalloids on the following param eters in children with DSS: Recurrence of shock. Requirement for rescue intravenous uids. Mortality. Total volume of intravenous uid given. 15 Philippine Journal of Microbiology and Infectious Diseases Vol. 39, Issue 1, January-June 2010 Colloids Need for diuretics. Change in hematocrit level. Change in pulse rate. This systematic review aims to compare the adverse effects associated with the administration of colloids versus crystalloids in children with DSS. experts, and researchers in the eld for additional information on unpublished and ongoing trials. There was no language restriction. Methods of the review: Two reviewers independently assessed the eligibility of potentially relevant trials based on the selection criteria. The reviewers independently assessed the methodologic quality of each trial using the Cochrane Infectious Diseases Group criteria. Studies were assessed as â€Å"high quality† if randomization and allocation concealment were adequate, blinding maneuvers were performed, and intent-to-treat analysis was done. Studies were assessed as â€Å"fair quality† if any subtle biases were present: unclear allocation concealment; absence of blinding; and no intent-to-treat analysis. Studies were considered â€Å"low-quality† if any of the following biases was seen: inadequate randomization and allocation concealment and/or signi cant differences between the treatment group and control group in terms of known predictors of outcome; obvious differences in the general quality of care received by subjects in both groups; marked difference in drop-out rates; and outcome detection methods were different for both groups. Two reviewers independently abstracted data from the studies including baseline characteristics of patients, inclusion and exclusion criteria, types of intervention or study uids, and dosing regimen. The information on each outcome measure and the number of affected patients were also obtained. Data were analyzed using the Review Manager (RevMan) Version 5. 0. For dichotomous data, the risk ratio, or the probability that an event will occur, was determined for each comparison. The need for diuretics, need for rescue uid, and recurrence of shock were all considered dichotomous outcomes. For continuous data, the weighted mean differences were determined. The decrease in hematocrit and pulse rate from baseline and the total volume of intravenous uids administered were all analyzed as continuous data. Missing data such as standard deviations were derived using the 95% con dence intervals provided. SEARCH METHODOLOGY Criteria for considering studies for this review: Studies included in this review were randomized controlled trials in which children less than 18 years of age were given either colloid or crystalloid intravenous uid within the rst 2 hours after being diagnosed with DSS. The diagnosis of DSS was based on the World Health Organization (WHO) criteria, as shown in Appendix 2, which included hemoconcentration associated with the characteristic plasma leakage, presence of circulatory compromise as evidenced by narrowing of pulse pressure, hypotension, decreased perfusion, and decreased urine output. The primary outcome measures included the number of episodes of shock, the requirement for rescue intravenous uids, and mortality. The secondary outcome measures included the change from the baseline in pulse rate, the change from the baseline of hematocrit, the need for diuretics, the total volume of intravenous uid given, and adverse effects. Search strategy: We searched the following databases for relevant studies: Medline 1966 to June 2008; the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2008); and the Herdin database of the Philippines 1964-2008. The search strategy combined the terms â€Å"pediatrics†, â€Å"child†, â€Å"children†, â€Å"dengue†, â€Å"dengue hemorrhagic fever†, â€Å"dengue shock†, and â€Å"intravenous uids† with the Cochrane Highly Sensitive Search Strategy phases one and two as contained in the Cochrane Reviewer’s Handbook, as shown in Appendix 3. Conference proceedings and local journals were handsearched for potentially relevant trials. The reference lists of articles were examined to identify additional relevant studies. We also searched institutional libraries, including libraries in universities, hospitals, and pharmaceutical companies. We contacted colleagues, 16 Philippine Journal of Microbiology and Infectious Diseases Vol. 39, Issue 1, January-June 2010 Colloids Study Flow Diagram Potentially relevant randomized controlled trials identified through Medline, Herdin, and CENTRAL searches (n=4) Trials excluded (n=2) Included patients with septic shock (n=1) Assessed difference between clinical and laboratory diagnosis of dengue (n=1) Articles obtained from colleagues (n=2) Trial excluded (n=1) Used both colloids and crystalloids in a single patient (n=1) Links to related articles and other references examined (n=2) Trial excluded (n=1) Compared colloid with blood plasma (n=1) Randomized controlled trials comparing colloids and crystalloids in pediatric dengue shock (n=4) The formula for grouping data and imputing group means and group standard deviations were obtained from the Cochrane Handbook of Systematic Reviews. 0 We assessed heterogeneity using the chi-square test for heterogeneity (P value 50% indicated moderate degree of heterogeneity; a value of 75% indicated large degree of heterogeneity across trials. For outcome measures with signi cant heterogeneity, the sources of heterogeneity were explored by doing sensitivity analysis according to methodologic quality. excluded two trials: one trial was on the assessment of the differences between the clinical and laboratory diagnosis of dengue, and the other trial included patients with septic shock. On review of the reference lists of relevant articles, two more trials were identi ed: one ful lled the selection criteria while the other was excluded since it used both colloids and crystalloids for each study participant. We obtained two additional studies from colleagues. One trial was excluded because it compared a colloid with blood plasma. Included studies: Four randomized controlled trials on the use of colloids and crystalloids in children with DSS were included with a combined sample size of 694 (colloids=410, crystalloids=284). -9 All the trials used WHO criteria for the diagnosis of DSS. 2 Participants: The patients were under 18 years old, with ages ranging from 1-15 years. All patients were Asians: 655 were Vietnamese and 39 were Indonesian. In all the studies, none of the patients received any intravenous uids prior to the study. 17 RESULTS Search results: As shown in the study ow diagram, we identi ed four potentially relevant randomized controlled trials on the use o f colloids and crystalloids through Medline and CENTRAL searches. We Philippine Journal of Microbiology and Infectious Diseases Vol. 9, Issue 1, January-June 2010 Colloids Table 1. Characteristics of Included Studies Author, Year Nhan 2001 7 Study Population 230 Vietnamese children clinically diagnosed DHF DHF grade III = 222 DHF grade IV = 8 1-15 years old Intervention Study uids Lactated Ringer’s solution, isotonic saline, dextran, gelatin Fluid rate DHF grade III: 20mL/kg for 1 hr DHF grade IV: 20ml/kg for 15min, then 20mL/kg over the following hour Study uids Lactated Ringer’s solution, starch, dextran Fluid rate 15mL/kg for 1 hr, then 10mL/kg for the 2nd hr Outcomes Data presented are those of DHF grade III patients only: PPRT, reshock rate, time to 1st episode of reshock, change from baseline of hematocrit and pulse rate, volume of uid infused, requirement for rescue uid, volume of rescue uid used, requirement for diuretic, mortality Change from baseline of hematocrit; total volume of rescue uid used after initial resuscitation, total volume of uid given, requirement for further uid resuscitation, requirement for diuretic, mortality, length of hospital stay; depth of pleural effusion, new bleeding after study entry, clinical uid overload, volume of ascites Change from baseline of hematocrit, cardiac index, pulse rate and pulse pressure, requirement for further uid resuscitation, requirement for diuretic, duration of shock, episodes of reshock, mortality Change from the baseline of hematocrit, hemoglobin, pulse rate and pulse pressure; total volume of uid given, episodes of reshock, mortality Adverse Reactions None stated Wills 20056 51 2 Vietnamese children with clinical DSS Moderate shock = 383 Severe shock = 129 2-15 years old Allergic type reactions, transient high fever and rigors without cardio-respiratory compromise; urticarial rashes Dung 19998 50 Vietnamese children with clinical DSS 5-15 years old Study uids Lactated Ringer’s solution, isotonic saline, dextran, gelatin Fluid rate 20mL/kg for 1 hr, then 10mL/kg for the 2nd hr Study uids Lactated Ringer’s solution, gelatin Fluid rate 20mL/kg as initial volume of uid resuscitation None stated Prasetyo20089 39 Indonesian children with clinical DSS 1-13 years Adverse reactions in coagulation, liver and renal functions and acid-base equilibrium; severe allergic type reactions DHF: dengue hemorrhagic fever DSS: dengue shock syndrome PPRT: pulse pressure recovery time One study included both DHF grades III and IV patients9, while two studies presented data on DHF grade III patients only. 7-8 The study by Wills (2005) grouped patients into those with moderate and severe shock. The subset of patients with severe shock was not given the chance to receive crystalloid uids and was not included in this review. Children were excluded in the study if they had severe hemorrhagic manifestation for which transfusion was likely7, chronic disorders7, malnutrition9, and heart, renal, liver, and lung diseases. 9 Interventions: The colloids used were dextran 706-8, gelatin7-8, and hydroxyethyl starch. 6,9 The crystalloids used were lactated Ringer’s solution69 and isotonic saline. 7-8 In three studies6-8, the study uids were administered initially at 20mL/kg for 1 hr for DHF grade III patients and 20ml/kg for 15min. Subsequently, uids were given depending on each study’s protocol: 20mL/kg over the following hour for DHF grade IV patients7; 15mL/kg for 1 hour, then 10mL/kg for the 2nd hour6; and 20mL/kg for 1 hour, then 10mL/kg for the 2nd hour. The study by Prasetyo9 administered an initial volume of 20mL/kg to all patients. Table 2. Characteristics of Excluded Studies Author, Year Hung 2006 Martinez-Vega 2006 Tatura 2008 Upadhyay 2005 Reason for Exclusion The study used both colloids and crystalloids in all patients with DSS. The study did not compare colloids and crystalloids; it was based on the assessment of the difference between clinical and laboratory diagnosis of dengue. The study compared gelatin solution with blood plasma. The study participants were children with septic shock. 18 Philippine Journal of Microbiology and Infectious Diseases Vol. 39, Issue 1, January-June 2010 Colloids Table 3. Methodological Quality of Included Studies Author Year Dung 19998 Randomization Adequate Allocation Concealment Adequate-treatment pack numbers contained in opaque envelopes Adequate-treatment pack numbers contained in opaque envelopes Computer generated random numbers, treatment packs prepared by independent staff Not stated Blinding Double-blind each treatment bottle covered in black tape Double-blind Double-blind Intent-to-treat Analysis Not stated Nhan 20017 Wills 20056 Sequential randomization Adequate, strati ed by pulse pressure Random assignment, strati ed to DHF 3 or 4 Yes Yes Prasetyo 20089 Not stated Not stated Outcomes: The outcomes measured included the following: changes from baseline of hematocrit6-9 and pulse rate7-9; total volume of rescue uid used after initial resuscitation6,7 and requirement for further uid resuscitation6-8; total volume of intravenous uids given6,7,9; requirement for diuretics6-8; and number of patients with recurrences of shock. -9 Other parameters evaluated were the following: change in hemoglobin9, pulse pressure8,9 and pulse pressure recovery time7; cardiac index8; duration of shock8; time to rst episode of reshock7; length of hospital stay in days6; and mortality. 6-9 The study by Prasetyo further determined disorders of blood coagulation, liver and renal function parameters, and acid-base equilibrium. 9 The study by Wills reported depth of pleural effusion, new bleeding after study entry, clinical uid overload, and volume of ascites. 6 Two studies determined severe allergic type reactions after intravenous uid infusion. 6,9 The characteristics of the included studies are summarized in Table 1. Excluded studies: Trials that did not compare rystalloids and colloids or were not used on pediatric patients with DSS were excluded from this review. 11-14 The characteristics of the excluded studies are summarized in Table 2. Methodological quality of included studies: Two studies were assessed as â€Å"high quality. †6. 7 The study by Prasetyo had unclear alloc ation concealment and did not mention blinding or intent-to-treat analysis, as shown in Table 3. The study by Dung also did not state whether intent-to-treat analysis was done. Both were rated as fair quality. Despite randomization, the study of Nhan had unequal distribution of more severely ill patients: dextran group had fewer patients with very low pulse pressure, but had patients with lowest mean pulse rate at presentation. Primary outcomes: The meta-analysis of the trials showed no statistically signi cant difference in reducing the risk for recurrence of shock (3 trials, RR 0. 92, 95% CI 0. 62 to 1. 38) and the need for rescue colloids (2 trials, RR 0. 90, 95% CI 0. 70 to 1. 16) after the initial resuscitation. Test for heterogeneity was not signi cant for both outcomes, as shown in Figures 1 and 2. Figure 1. Number of Patients Who Had Recurrence of Shock After the Initial Fluid Resuscitation Study or Subgroup Dung 1999 Nhan 2001 Prasetyo 2008 Total (95% CI) Colloid Crystalloid Risk Ratio Events Total Events Total Weight M-H, Fixed, 95% CI 2 31 1 25 111 19 155 2 32 3 25 5. 4% 111 86. 7% 20 7. 9% 156 100. 0% 1. 00 [0. 15, 6. 55] 0. 97 [0. 64, 1. 47] 0. 35 [0. 04, 3. 09] 0. 92 [0. 62, 1. 38] Risk Ratio M-H, Fixed, 95% CI Total events 34 37 Heterogeneity: Chi? = 0. 82, df = 2 (P = 0. 66); I? = 0% Test for overall effect: Z = 0. 40 (P = 0. 69) 0. 005 0. 1 1 10 200 Favours colloids Favours crystalloids Favours experimental Favours control 19 Philippine Journal of Microbiology and Infectious Diseases Vol. 39, Issue 1, January-June 2010 Colloids Figure 2. Number of Patients Who Needed Rescue Colloids After the Initial Fluid Resuscitation Study or Subgroup Nhan 2001 Wills 2005 Total (95% CI) colloid crystalloid Risk Ratio Events Total Events Total Weight M-H, Fixed, 95% CI 32 74 111 255 366 37 40 111 41. 0% 128 59. 0% 239 100. 0% 0. 86 [0. 58, 1. 28] 0. 93 [0. 7, 1. 28] 0. 90 [0. 70, 1. 16] Risk Ratio M-H, Fixed, 95% CI 77 Total events 106 Heterogeneity: Chi? = 0. 08, df = 1 (P = 0. 78); I? = 0% Test for overall effect: Z = 0. 81 (P = 0. 42) 0. 01 0. 1 1 10 100 Favours colloids Favours crystalloids Favours experimental Favours control All study participants recovered fully, ex cept for one child in the colloid group (starch) who died of profound shock and gastrointestinal bleeding. 6 Secondary outcomes: There was no signi cant difference between patients who received colloids and crystalloids in terms of the total volume of intravenous uids given during resuscitation (WMD 0. 80 ml/kg, 95% CI -1. 68 to 3. 8) and the need for diuretics (RR=1. 17, 95% CI 0. 84 to 1. 64). The test for heterogeneity was not signi cant, as shown in Figures 3 and 4. Hemodynamic variables: On the other hand, there was a signi cant improvement in hematocrit levels from the baseline after the rst two hours of uid resuscitation (WMD -7. 87, 95% CI -8. 52 to 7. 22), but with a large degree of heterogeneity, as shown in Figure 5. Sensitivity analysis removing the study of Wills (2005), which used median instead of mean, removed the heterogeneity and a statistically signi cant reduction in hematocrit levels remained (WMD -3. 37, 95% CI -5. 94 to -0. 80), as shown in Figure 5a. The study of Wills (2005) also showed a signi cant reduction in the median hematocrit levels two hours after the initial resuscitation (25% for the dextran group versus 9% for the Ringer’s lactate group, p 35% Improvement IV therapy by crystalloid, successively reducing the ow from 10 to 6, 6 to 3ml/kg/hr Discontinue after 24-48 hrs Philippine Journal of Microbiology and Infectious Diseases Vol. 39, Issue 1, January-June 2010 25 Colloids Appendix 2. World Health Organization Criteria for the Diagnosis of Dengue Fever and Dengue Hemorrhagic Fever DF/DHF DF Grade* Symptoms Fever with two or more of the following signs, headache, retro-orbital pain, myalgia, arthralgia I Above signs plus positive tourniquet test Above signs plus spontaneous bleeding Laboratory Leukopenia occasionally. Thrombocytopenia, may be present, no evidence of plasma loss Thrombocytopenia 100,000, Hct rise 20% Thrombocytopenia 100,000, Hct rise 20% Thrombocytopenia 100,000, Hct rise 20% DHF DHF II DHF III Above signs plus circulatory failure (weak pulse, hypotension, restlessness) Profound shock with undetectable blood pressure and pulse DHF IV Thrombocytopenia 100,000, Hct rise 20% *DHF Grade III and IV are also called as Dengue Shock Syndrome (DSS) 26 Philippine Journal of Microbiology and Infectious Diseases Vol. 39, Issue 1, January-June 2010 Colloids Appendix 3. Search Strategy Philippine Journal of Microbiology and Infectious Diseases Vol. 39, Issue 1, January-June 2010 27

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