Saturday, May 16, 2020
The humoral theory is one of the oldest theories of Medicine that proposed that our bodies are made up of four different humours: black bile, blood, phlegm, and yellow bile. It was believed that while in good health the humours were in a harmonious balance throughout the body but illness is said to have disrupted that balance causing one or more humour to become disordered. It is also said that the mind is effected by the equilibrium of the four temperaments known as melancholic, sanguine, choleric, and phlegmatic and that they dispersed to make up certain characteristics or personality traits. Critics have long described Shakespeare as using these humours and temperaments as a way for the audience to understand the character, plot and other aspects of his plays. In such plays as Romeo and Juliet where critics have described Romeo as being a melancholy figure it is exceptionally brought about by using the four humours involved in the humoral theory that is said to have first originat ed by Hippocrates and later elaborated on by Galen. The four humours include Black Bile which is related to the melancholic temperament and said to be associated with the element earth, the season of winter, the planet Saturn, the spleen, and cold and dry qualities. The humour Blood is related to the sanguine temperament and associated with the element air, the season spring, the planet Jupiter, the heart, and hot and moist qualities. While Phlegm is associated with the temperament phlegmaticShow MoreRelatedWilliam Shakespeare s Romeo And Juliet1998 Words Ã |Ã 8 PagesIn the plays, Romeo and Juliet and 1 Henry VI, by William Shakespeare, the concept of humoral theory helps to explain many of the behaviors the characters display in the plays. Humoral theory works to explain workings within the human body. According to the Welcome Library of London, Ã¢â¬Å"Humors existed as liquids within the body and were identified as blood, phlegm, black bile and yellow bile. These were in turn associated with the fundamental elements of air, water, earth and fire.Ã¢â¬ The elements are
Pablo Picasso, also known as Pablo Ruiz y Picasso, was singular in the art world. Not only did he manage to become universally famous in his own lifetime, he was the first artist to successfully use mass media to further his name (and business empire). He also inspired or, in the notable case of Cubism, invented, nearly every art movement in the twentieth century. Movement, Style, School or Period: Several, but best known for (co-)inventing Cubism Date and Place of Birth October 25, 1881, MÃ ¡laga, Spain Early Life Picassos father, fortuitously, was an art teacher who quickly realized he had a boy genius on his hands and (almost as quickly) taught his son everything he knew. At the tender age of 14, Picasso passed the entrance exam to the Barcelona School of Fine Arts - in just one day. By the early 1900s, Picasso had moved to Paris, the capital of the arts. There he found friends in Henri Matisse, Joan MirÃ ³ and George Braque, and a burgeoning reputation as a painter of note. Body of Work Before, and shortly after, moving to Paris, Picassos painting was in its Blue Period (1900-1904), which eventually gave way to his Rose Period (1905-1906). It wasnt until 1907, though, that Picasso really raised a commotion in the art world. His painting Les Demoiselles dAvignon marked the beginning of Cubism. Having caused such a stir, Picasso spent the next 15 years seeing what, exactly, could be done with Cubism (such as putting paper and bits of string in a painting, thus inventing the collage). The Three Musicians (1921), pretty much summed up Cubism for Picasso. For the rest of his days, no one style could maintain a hold on Picasso. In fact, he was known to use two or more different styles, side by side, within a single painting. One notable exception is his surrealistic painting Guernica (1937), arguably one of the greatest pieces of social protest ever created. Picasso lived long and, indeed, prospered. He grew fabulously wealthy from his phenomenal output (including erotically themed ceramics), took up with younger and younger women, entertained the world with his outspoken remarks, and painted almost right up until he died at the age of 91. Date and Place of Death April 8, 1973, Mougins, France Quote Only put off until tomorrow what you are willing to die having left undone.
Wednesday, May 6, 2020
OMAM Loneliness and Companionship Of Mice and Men is a skillful novel, that portrays the idea of loneliness throughout the novel. Two men, George and Lennie are there for each other through everything. They also have their tiffs just like any other friends. There are several clearly stated themes running through the novel. But, the two themes that interact with each other are loneliness and companionship. Many of the characters do suffer from loneliness in the novel Of Mice and Men. George lets everybody know early on in the novel that he is lonely. When George reminds Lennie that Guys like us, that work on ranches, are the loneliest guys in the worldÃ¢â¬ (Steinbeck Section 1). Men like George who travel from farm to farm usually never have anyone to look to for companionship and protection. As the story goes on, Candy, Crooks, and CurleyÃ¢â¬â¢s wife all state their deep loneliness. Crooks says, Ã¢â¬Å"A guy goes nuts if he aint got nobody. Dont make no difference who the guy is, longs hes with you. I tell ya, I tell ya a guy gets too lonely an he gets sick (80). In a world with no friends to confide in, random people will have to do. Each of the characters search for a friend, someone to confide in and be able to talk to on an everyday basis, as Crooks says. In the end, however, companionship of CurleyÃ¢â¬â¢s kind seems impossible to find. For George, when Lennie dies, Georg eÃ¢â¬â¢s dreams and hopes of finding a companion disappears. In Of Mice and Men, several relationships appearShow MoreRelatedOf Mice And Men By John Steinbeck2184 Words Ã |Ã 9 Pagesthe 1930Ã¢â¬â¢s and he used the line from an 18th Century poem by Robert Burns as the title of the story. Ã¢â¬Å"Of Mice and MenÃ¢â¬ (Ã¢â¬Å"OMaMÃ¢â¬ ) as a title foreshadows the idea portrayed by Burns in his poem Ã¢â¬Å"To a mouseÃ¢â¬ because in this poem the mouseÃ¢â¬â¢s house was destroyed in an accidental mistake which implies dreams being shattered and depression along with death following as a result. Loneliness is a key theme in this book which outlines the harsh life faced by the ranch workers and the setting that they lived inRead MoreOf Mice and Men and Macbeth Conflict1902 Words Ã |Ã 8 Pagesare indeed affiliated. OMAM tells the story of a sharp witted man and his simple friend who find work in CaliforniaÃ¢â¬â¢s Salinas Valley. They are driven by a shared dream, that one day they will own their own property and Ã¢â¬Å"live off the fatta the lanÃ¢â¬ . George serves as LennieÃ¢â¬â¢s protector, as Lennie is mentally retarded. Ã¢â¬Å"HeÃ¢â¬â¢s awright, just aint brightÃ¢â¬ LennieÃ¢â¬â¢s fetish for soft things and his ignorant behaviour, often lands them both in trouble. Many of the characters in OMAM admit to suffering fromRead MoreOf Mice And Men And Macbeth Conflict Essay1899 Words Ã |Ã 8 Pagesare indeed affiliated. OMAM tells the story of a sharp witted man and his simple friend who find work in CaliforniaÃ¢â¬â¢s Salinas Valley. They are driven by a shared dream, that one day they will own their own property and live off the fatta the lan. George serves as LennieÃ¢â¬â¢s protector, as Lennie is mentally retarded. HeÃ¢â¬â¢s awright, just aint bright LennieÃ¢â¬â¢s fetish for soft things and his ignorant behaviour, often lands them both in trouble. Many of the characters in OMAM admit to suffering fromRead MoreAnalysis Of Steinbeck s Of Mice And Men 1971 Words Ã |Ã 8 Pages Loneliness Taking its Toll Ã¢â¬Å"A guy goes nuts if he ainÃ¢â¬â¢t got nobody. DonÃ¢â¬â¢t make no difference who the guy is, long s heÃ¢â¬â¢s with yaÃ¢â¬ ¦ a guy gets too lonely anÃ¢â¬â¢ he gets sickÃ¢â¬ (Steinbeck 72-73). During the Great Depression, it wasnÃ¢â¬â¢t uncommon to endure this type of loneliness. Candy, one of Steinbeck s characters, is a migrant worker who was badly injured on a ranch and has been there ever since. Another character from SteinbeckÃ¢â¬â¢s novella is Lennie, Lennie is mentally slow and as a migrant worker
Global warming and the greenhouse effect are issues discussed by scientists all the time. A natural process that keeps earths temperature at a livable rate is called the greenhouse effect. The energy from the sun warms up the earth when the rays from the sun are absorbed by greenhouse gasses. The gasses then become trapped in the atmosphere. Carbon dioxide, water vapor, methane and nitrous oxide are the most common greenhouse gasses. Greenhouse gases cause the radiant heat of the sun to be trapped in the Earths lower atmosphere which causes global warming. If there werenÃ¢â¬â¢t any greenhouse gasses, the earth would be really cold due to very little sun rays being absorbed on the earth. Global warming can andÃ¢â¬ ¦show more contentÃ¢â¬ ¦Every time the temperature keeps rising, the more carbon dioxide will be released. When this process gets going, it is very hard to keep in control. Methane is another greenhouse gas. Methane is a greenhouse gas whose molecules absorb heat trying to escape to space. Natural sources include wetlands, swamps and marshes, termites, and oceans. (Methane) Methane gases are released into the atmosphere. Atmospheric methane has doubled since the Industrial Revolution and has Ã¢â¬Å"contributed 20 percent to the enhancement of the greenhouse effect, second only to carbon dioxideÃ¢â¬ . (Methane) A major effect of global warming is there will be higher temperatures and it will affect how the water cycle works. Places on the earth will receive more rain than others. There will be a great amount of evaporation going on from the rivers, lakes and oceans due to a increase in the temperature. This could be a good thing for some people needing rain and a bad thing for other people who get to much rain. While the temperature is on the rise there will be greater amount of rains all over. In return with all of the rains this could help farmers. It would extend the growing season for crops. This would greatly help out the farmers because they would be making more money. While this is the positive side of the rain, this could also hurt the farmers. There are some crops that out there that will die with to much rain. ThereShow MoreRelatedGlobal Warming And Climate Change974 Words Ã |Ã 4 Pagesabout global warming, whether it is true or false. Is there evidence to prove that global warming has impacted the climate due to the rise in the earthÃ¢â¬â¢s temperature? Climate change is a problem that is worldwide that should be reviewed. The rise in the earthÃ¢â¬â¢s temperature has caused some impact to the weather and climate changes to many places worldwide. This rise in temperature has the potential of causing drastic changes to the earth in many ways. It is time to view the global warming concernsRead MoreClimate Change Of Global Warming924 Words Ã |Ã 4 Pages Figure 0.1 shows the different effects of global warming. Global warming is the warming of our planet at an extreme rate. The EarthÃ¢â¬â¢s climate has warmed by 7.8OC since 1880. (Quick facts about science, 2015). What causes global warming? The cause of global warming is the carbon dioxide. This acts like a blanket. Protecting the earth, and heating the earth. Sun rays would normally bounce around the earth, but with the blanket, the sun rays heat the blanket which heats the earth. (Petersen ScienceRead MoreGlobal Warming And Climate Change1398 Words Ã |Ã 6 Pages Global warming and climate change have been frequent topics of discussion over the past several years. Although people tend to focus on the politics, it is important to look past the media aspects of it into the cold hard facts of what our Earth is currently experiencing, and what has caused it in the first place. The cause of climate change includes natural causes, but human causes are what is generating such a rapid global temperature change. ItÃ¢â¬â¢s time that the ways in which humanity affectsRead MoreClimate Change And Global Warming1060 Words Ã |Ã 5 PagesClimate change (Klaus) 1000 The terms Ã¢â¬Å"global warmingÃ¢â¬ , Ã¢â¬Å"climate changeÃ¢â¬ or Ã¢â¬Å"greenhouse effectÃ¢â¬ have become more than just parts of the popular lexicon as they rather are subject of public discussions, scientific research or political debates. Despite the popularity and the ubiquity of these terms, the publicÃ¢â¬â¢s theoretical and conceptual understanding of them and their causal relations is often based on superficial knowledge and buzzwords or caricatures outlined and depicted in several popular mediaRead MoreClimate Change : Global Warming1194 Words Ã |Ã 5 PagesDonya Curtis April 19, 2017 English 1001-rough draft Global Warming Global warming is one facet of the broader term climate change. It is the increase in the average temperature of the Earth s surface air and oceans from the mid 20th century and the projected continuation. The Global warming is primarily the consequence of building up greenhouse gasses in the atmosphere. Emission rates for most important anthropogenic greenhouse gas, CO2, have increased 120 fold in the past 140 years. WhileRead MoreClimate Change and Global Warming1074 Words Ã |Ã 5 PagesClimate change and Global Warming are out of control. This means that, no matter what policies, processes or actions are implemented, the Earth as we know it will never be the same again. There is significant evidence to support this hypothesis. The dilemma becomes whether we can limit the damage and adapt to a new status quo or not. Rising sea levels and the damage caused by this phenomenon has irreversible impacts on coastlines worldwide. Damage to sensitive reef systems cannot be fixed. This alsoRead MoreClimate Change And Global Warming1022 Words Ã |Ã 5 PagesWhat = Climate Change Who = Emma, Aoife, Julia, Rachael, Mariah and CÃ ©line What is it? Climate Change is a change in the demographic distribution of weather patterns, and related change in oceans, land surfaces and ice sheets, happening over time scales of decades or longer. ItÃ¢â¬â¢s the worldÃ¢â¬â¢s greatest threat. Climate change is the change in temperature over a period of time. It involves the greenhouse effect and global warming. Where is it? It is an issue affecting everyone everywhere. ClimateRead MoreClimate Change And Global Warming1474 Words Ã |Ã 6 Pagesphenomenon, known as Ã¢â¬Å"smogÃ¢â¬ became an often daily occurrence in big, urbanized cites across the globe. Also, Al GoreÃ¢â¬â¢s book, An Inconvenient Truth, popularized the issue of climate change and global warming as a result of the damage that the modern world has done to the atmosphere. He noted that people resist the facts about climate change due to the inconvenience of changing their lifestyles. But, uninhibited industrialization of several countries has led to intense modernization and revolution of theRead MoreClimate Change And Global Warming928 Words Ã |Ã 4 PagesThis paper will discuss climate change and global warming on the economy. The paper also gives a description on climate change and global warming. As well as what it hold for future business owners. It will also discuss what the government is doing about climate change/global warming. Climate change is a long-term shift in the statistics of the weather (including its averages). For example, it could show up as a change in climate normal (expected average values for temperature and precipitation)Read MoreClimate Change And Global Warming1630 Words Ã |Ã 7 PagesClimate Related Threats Global warming will lead to uncontrollable devastation such as famine, war, and economic instability. Climate change will accelerate the dislocation of hundreds of millions of people and the extinction of many species. The negative effects of climate change are obvious on every continent. Professor Le Quere, director of the Tyndall Centre for Climate Change Research at the University of East Anglia said, The human influence on climate change is clear. The atmosphere and
Tuesday, May 5, 2020
The Tang dynasty is one of ChinaÃ¢â¬â¢s most remarkable and glistening historic periods known today. The Tang dynasty established a strong centralized state system, starting in 618 after the fall of the Sui dynasty in the early seventeenth century. Although the early Tang monarchs were good rulers over all, one emperor in particular parts from the group. Ã¢â¬Å"Li Shih-minÃ¢â¬ who would assume the title of TÃ¢â¬â¢ai-tsung. TÃ¢â¬â¢ai-tsung was the son of the first emperor in the Tang dynasty Gaozu. He was a bold, energetic, and powerful emperor that was determined to solve the international problems that had destroyed past weaker dynasties. TÃ¢â¬â¢ai-tsung was responsible for the recreation of Chinese government. (Ã¢â¬Å"quote sourceÃ¢â¬ ) According to Ã¢â¬Å"source 1Ã¢â¬ at the top of the hierarchy was the emperor; below him were three administrations; council of the state, military affairs, and the censorate. The most important out of the three was the council of the state, which drafted policy, reviewed policy, and implemented policy. The military affairs directed the military under the control of the emperor. The censorate watched over the government and the government officials to prevent misgoverning and corruption. The new government policies set into place that TÃ¢â¬â¢ai-tsung had ingeniously derived led to the central state system working. The geographical area of the Tang Empire stretched across a vast part of China. ChangÃ¢â¬â¢an was the western capitol of the Tang dynasty, and became a centralized meeting place for traders, merchants, artist, and religious leaders. ChangÃ¢â¬â¢an became one of the richest and most powerful cities in the world at that time. The Tang dynasty flourished in part due to the new economic and trading ties with different regions. Trade was possible because the government maintained good foreign trade relation. The Tang Empire traded with India, Middle East, and Central Asia. Silk road connected ChangÃ¢â¬â¢an to Greece, Rome, and parts of Europe. This highway brought new products of trade to the countries which included silk, tea, herbs, spices and hand crafted items. The Tang dynasty is responsible for many great things, the dynasty had several world changing inventions, famous literature, and changing religious movements that would spark a revolution that would forever change the way Chinese people interacted and lived within society. One reason that the Tang Dynasty is known for being one of the best empires in Chinese history is because of the brilliant and world changing inventions that some of the greater minds in that era created, forever changing the way people lived. Inventions are essential for ever changing technologic advances towards a greater way of life and the Chinese understood this concept with the invention of making paper, gunpowder, printing technique and compass. All of which were not completely new concepts but the Tang Dynasty found ways to improve some of the already thought of inventions. The invention of paper making greatly contributed to the spread and development of civilization. Prior to the invention of paper making; bones, tortoise shells, and bamboo slips were all used as writing surfaces. As Chinese civilization developed the usage of their materials proved to be unsuitable, because they were extremely too heavy and took up a lot of space. The next material used in trying to make paper was the combination of hemp fiber and silk, but the quality of the material was found to be unsatisfactory. The use of that material also had far better uses . According to (Ã¢â¬Å"quoteÃ¢â¬ ) Xue fu wu che which is a Chinese idiom describing a learned man. The story behind paper making is that a scholar by the name of Hui Shi who lived during the Tang dynasty. He needed five charts to carry around his books while teaching. At the time books were made of wood and bamboo slips, so one could imagine how heavy and inconvenient they would be to carry from place to place. Not to mention how much space the books would take up. If a person had ten or more books that person might need a cart with wheels just to carry them around. Reading books at the time, a person would not only need to have brain power, but would also have to be in good physical condition. According to Chinese history experts Ã¢â¬Å"In 105 A. D. Cai Lun, a eunuch during the Tang dynasty, invented paper from worn fishnet, bark, and cloth. Ã¢â¬ The fact that these raw materials were available at such a low cost and easily able to obtain the process of making paper in large quantities just made sense! The technique of paper making was eventually exported to Korea in 384 A. D. Japan acquired the skill of making paper when a Korean monk traveled there taking the information and process with him. Paper making traveled to the Arab empire during a war between the Arabs and the Tang dynasty, when some of the soldiers of the Tang army, and paper making workers were captured during the war. Soon after, a paper factory was established in the Arab nation. In the eleventh century the skill of making paper was carried to India when Chinese monks traveled there in search for spiritual enlightenment. The skill then traveled the world from one continent to the next, eventually the skill was brought to America. The invention of paper is accredited to one of the greatest dynasties know in Chinese history, the Tang Dynasty. The Tang dynasty was also responsible for the invention of gunpowder. In Chinese, the word gunpowder is called, huo yao, which means flaming medicine. Unlike so many of the other Chinese inventions the making of gunpowder was pure accidental. Gunpowder is an invention that has had a profound effect on human society. Gunpowder was first discovered when alchemist was trying to make an elixir of immortality. According to legend Ã¢â¬Å"During the Tang dynasty, around 850 A. D. , an enterprising alchemist (whose name has been lost to history) mixed 75 parts saltpeter with fifteen parts charcoal and ten parts sulfur. This mixture had no discernable life-lengthening properties, but it did explode to an open flame. According to a text from the era, Ã¢â¬Å"smoke and flames result, so that (the alchemist) hands and faces have been burnt, and even the whole house where they were working burned down. Ã¢â¬ After the discovery of gunpowder the Chinese people found many useful purposes for this new and amazing invention. It is thought that the only use for gunpowder was for making fireworks, used by the Chinese during celebrations, such as, parades and ceremonial events for the emperor; but gunpowder was destined for greater usages. One usage of gunpowder was in weapons.
How many bald, six-foot-six, 250-pound volunteer firefighters in New Jersey wear droopy mustaches, aviator-style eyeglasses, and a the influence of nature versus key ring on the right side of the belt? nurture. The answer is two: Gerald Levey and Mark Newman. They are twins who were separated at birth. Each twin did not even know 25. 2 Describe developmental the other existed until they were reunitedÃ¢â¬âin a fire stationÃ¢â¬âby a research techniques. fellow firefighter. . . The lives of the twins, although separate, took remarkably similar 25. Discuss prenatal paths. Levey went to college, studying forestry; Newman planned to development. study forestry in college but instead took a job trimming trees. . . . Both men are unmarried and find the same kind of woman attractive: Ã¢â¬Å"tall, slender, long hair. Ã¢â¬ They share similar hobbies, enjoying hunting, fishing, going to the beach, and watching old John Wayne movies and professional wrestling. Both like Chinese food and drink the same brand of beer. We will write a custom essay sample on Influence of Nature and Nurture Developmental Research or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page learning outcomes 25. 1 Compare and contrastThe remarkable range of similarities we see in many pairs of identical twins raises one of the fundamental questions posed by developmental psychology, the study of the patterns of growth and change that occur throughout life. The question is this: How can we distinguish between the environmental causes of behavior (the influence of parents, siblings, family, friends, schooling, nutrition, and all the other experiences to which a child is exposed) and hereditary causes (those based on the genetic makeup of an individual that influence growth and development throughout life)?This question embodies the natureÃ¢â¬ânurture issue. In this context, nature refers to hereditary factors, and nurture to environmental influences. Although the question was first posed as a nature-versus-nurture issue, developmental psychologists today agree that both nature Gerald Levey and Mark Newman 282 Chapter 8 development and nurture interact to produce specific developmental patterns and outDevelopmental psychology The comes. Consequently, the question has evolved into How and to what degree branch of psychology that studies the do environment and heredity both produce their effects?No one grows up patterns of growth and change that free of environmental influences, nor does anyone develop without being occur throughout life. affected by his or her inherited genetic makeup. However, the debate over NatureÃ¢â¬ânurture issue The issue of the comparative influence of the two factors remains active, with different the degree to which environment and approaches and different theories of development emphasizing the environ- heredity influence behavior. ment or heredity to a greater or lesser degree (Pinker, 2002; Gottesma n Hanson, 2005; Rutter, 2006).For example, some developmental theories rely on basic psychological principles of learning and stress the role learning plays in producing changes in The natureÃ¢â¬ânurture issue behavior in a developing child. Such theories emphasize the role of the enviis a key question that is ronment in development. In contrast, other developmental theories emphasize pervasive throughout the the influence of oneÃ¢â¬â¢s physiological makeup and functioning on development. field of psychology, asking Such theories stress the role of heredity and aturationÃ¢â¬âthe unfolding of biohow and to what degree logically predetermined patterns of behaviorÃ¢â¬âin producing developmental environment and heredity change. Maturation can be seen, for instance, in the development of sex characproduce their joint effects. teristics (such as breasts and body hair) that occurs at the start of adolescence. Despite their differences over theory, developmental psychologists concur on some points. They agree that genetic factors not only provide the potential for specific behaviors or traits to emerge, but also place limitations on the emergence of such behavior or traits.For instance, heredity defines peopleÃ¢â¬â¢s general level of intelligence, setting an upper limit thatÃ¢â¬âregardless of the quality of the environmentÃ¢â¬âpeople cannot exceed. Heredity also places limits on physical abilities; humans simply cannot run at a speed of 60 miles an hour, nor will they grow as tall as 10 feet, no matter what the quality of their environment (Dodge, 2004; Pinker, 2004). Figure 1 lists some of the characteristics most affected by heredity. As you consider these items, it is important to keep in mind that these characteristics are not entirely determined by heredity, for environmental factors also play a role.Developmental psychologists also agree that in most instances environmental factors play a critical role in enabling people to reach the potential capabilities that their genetic background makes possible. If Albert Einstein had received no intellectual stimulation as a child and had not been sent to s tudy aler t Height Weight Obesity Tone of voice Physical Characteristics Blood pressure Tooth decay Athletic ability Firmness of handshake Age of death Activity level Intellectual Characteristics
Friday, April 17, 2020
Sepsis and Septic Shock Essay Sepsis refers to the uncontrolled systemic immune response to infection. It describes the condition known as systemic inflammatory response syndrome in which as infectious etiology is identified or suspected (Munford, 2001). The key element in sepsis is the overwhelming systemic inflammation as a result of the hostÃ¢â¬â¢s reaction to microbial invasion. It involves augmented inflammatory signals in response to an infectious insult that is not controlled by local inflammatory processes. Bacteremia, which is the presence of bacteria and in blood or septicemia, which is the presence of any microbial agent in the blood can lead to sepsis. When the regulatory controls that put the inflammatory response in check are unable to contain the overwhelming reaction, unaffected organs are involved and severe sepsis ensues which is characterized by multiorgan dysfunction. As the homeostatic counterregulatory mechanism fails, sepsis progresses to septic shock, which is the presence of hypotension along with along with organ dysfunction. The hypotension, which is defined as systolic blood pressure of less than 90 mmHg or 40 mmHg less than the patientÃ¢â¬â¢s usual blood pressure, is unresponsive to fluid resuscitation. Unlike sepsis which is reversible, patients in septic shock have unfavorable prognosis and usually succumb despite aggressive treatment (Munford, 2001).EpidemiologyOver 10 million cases of sepsis have been reported in the United States based on a 22-year period study of discharge data from 750 million hospitalizations (Martin, Mannino, Eaton, Moss, 2003). Annually, approximately 750,000 people develop sepsis and more than 210,000 cases are fatal (Bernard, Vincent, Laterre, Larosa, Dhainaut, Lopez-Rodriguez et al 2001; Hotchkiss Karl, 2003). Despite advances in critical care management, sepsis has a mortality rate of 30 to 50 percent and is among the primary causes of death in intensive care units (Bernard et 2003; Mitchell, Cotran, 1999). It is believed th at the increasing incidence of severe sepsis is due to the growing population among the elderly as a result of increasing longevity among people with chronic diseases and the high prevalence of sepsis developing among patients with acquired immune deficiency syndrome (Munford, p.798 2001).PathophysiologyThere are a lot of factors attributable to the development of sepsis. Several studies have conflicting results on the pathologic basis of the disease and the exact mechanism involved has not been elucidated. The pathogenesis of sepsis is a series of complex interactions between offending microorganism and the host inflammatory, immune and coagulation responses. The accepted theory is that sepsis results from an uncontrolled inflammatory response in which our own defense system becomes so powerful that it causes more damage to our organs than the etiologic agent of the initial infection Hotchkiss Karl, 2003). This is based on the overstimulated immune response seen in studies of anim al models of sepsis which does not seem to correlate which the clinical picture in humans. Clinical trials involving anti-inflammatory agents have not been successful in patients with sepsis which led investigators to question if sepsis is indeed the result of uncontrolled inflammation (Hotchkiss Karl, 2003). In fact, sepsis with organ dysfunction is attributed to an inadequate immune response to primary local infection which allowed it to spill into the bloodstream and the ensuing tissue injury is primarily caused by superantigens and other virulence factors from the infecting microorganism (Russel, J.A., 2006).Approximately 70 percent of cases of septic shock are caused by gram-negative bacilli which produce endotoxin, hence the term endotoxic shock (Mitchell, Cotran, 1999). The endotoxins are the lipopolysaccharides(LPS) from the bacterial cell wall that are released after the wall is degraded during an inflammatory response. The reproduction of the hemodynamic picture of septi c shock through the injection of LPS alone shows that LPS is one of the main culprits of septic shock. The complex inflammatory cascade caused by LPS eventually leads to hypoxic injury and the multi organ failure is mostly evident in the brain, heart, kidneys, lungs, and gastrointestinal tract. The widespread hypoxia during septic shock causes the brain to develop ischemic encephalopathy while in the heart, cardiac muscles undergo coagulation necrosis and subendocardial hemorrhages. The kidneys undergo acute tubular necrosis as a result of extensive ischemic injury. This results into electrolyte disorders, oliguria and anuria which are severe complications of sepsis. Despite the high resistance of lungs tissues to hypoxic injury, diffuse alveolar damage can be seen in severe bacterial sepsis. In the gastrointestinal tract, hemorrhagic enteropathy develops which appears as patchy mucosal hemorrhages and necrosis. The liver undergoes fatty change and in severe ischemic injury, central hemorrhagic necrosis can be seen (Mitchell, Cotran, 1999).Clinical FeaturesThe clinical manifestations of sepsis are usually superimposed with the signs and symptoms of the primary infection and other underlying medical condition of the patient.However, in the course of the disease, an increasing intensity of inflammatory response to infection becomes evident although the rate varies among patients. Hyperventilation is usually one of the early signs. Manifestations of ischemic encephalopathy such as disorientation and confusion may also occur early in sepsis. They are usually seen among the elderly and in patients with preexisting neurocognitive deficits (Munford, 2001). Patients with hypotension usually presents with weak but rapid pulse accompanied by tachypnea and cold, clammy skin. However, patients in septic shock may be initially warm due to peripheral vasodilation in the skin (Mitchell, Cotran, 1999). It should be noted that some patients with sepsis are normothermic and e ven in the presence of infection, fever can be absent especially in neonates, elderly, and patients with uremia or suffering from alcoholism (Munford, p.801 2001).The occurrence of disseminated intravascular coagulation or DIC, which results from the widespread activation of the coagulation system, can predispose patients to ischemic necrosis especially to those with hypotension. This leads to skin lesions seen as pustules, cellulites, bullae or hemorrhagic lesions. Gastrointestinal involvement manifests as nausea, vomiting, diarrhea and ileus. Patients with stress ulcers may present with upper gastrointestinal bleeding. In cases of prolonged and severe hypotension, ischemic bowel necrosis may occur as well as acute hepatic injury. Elevation of serum levels of conjugated bilirubin often leads to cholestatic sepsis. Liver function test may reveal elevated blood levels of alkaline phosphatase which along with the elevated bilirubin represent an underlying hepatocellular or canalicular dysfunction (Munford, 2001).Treatment and PrognosisPatients with sepsis requires urgent management which is best accomplished in an intensive care setting by medical specialist experienced in the care of critically ill patients. The management entails immediate treatment of the focus of infection while providing adequate hemodynamic and ventilatory support.The appropriate antimicrobial therapy should be given immediately based on blood culture and sensitivity although an empiric initial treatment should be started based on known pathogens at identified sites of infection. An adequate antibiotic cover should include therapy against gram-positive and gram-negative microorganism. Pending results from blood cultures, empiric antimicrobial therapy can be based on several factors, especially in patients with no obvious source of infection. In immunocompetent adults, acceptable regimens include ceftriaxone or ticarcillin-clavulanate or piperacillin-tazobactam and imipenem-cilastin or mero penem. Gentamycin or tobramycin may be added to these regimens. If the causative agent is suspected to be methicillin-resistant staphylococcous areus, vancomycin should be added to these regimens (Munford, 2001). In patients with AIDS, ceftazidime, tircacillin-clavilanate or piperacillin-tazobactam plus tobramycin should be used. In patients with drug allergy to beta lactams, ciprofloxacin plus vancomycin and tobramycin should be used (Munford, 2001). Other factors to be considered are the presence of neutropenia or neutrophil count of less than 500 per microliter, splenectomy and history of intravenous drug abuse. These patients require appropriate antimicrobial cover based on their higher susceptibility to certain microorganisms.The immediate removal of the focus of infection is also important in the successful management of patients with sepsis. Sites of infection should be identified immediately and appropriate drainage should be done when possible. In patients with indwelling i ntravenous catheters, microbial cultures should be done and a new catheter should be placed in another site. Adequate hemodynamic and respiratory support should also be provided especially in patients with septic shock to prevent tissue injury secondary to ischemia. The pulmonary wedge pressure and central venous pressure should be monitored constantly. Metabolic support should also be provided. The urine output should be watched closely for oliguria and anuria. Diuretic therapy with furosemide may be used (Munford, 2001).Despite aggressive treatment, many patients with severe sepsis and septic shock succumb to the disease. Several new agents have been developed which should promising outcome in averting death. These are drugs that neutralize the bacterial endotoxin such as monoclonal antibodies to endotoxins and drugs that interfere with the mediators of inflammatory response such as monoclonal antibodies to tumor necrosis factor alpha. Another promising drug for severe sepsis is d rotrecogin alfa or recombinant human activated protein C which has shown antithrombotic, antiinflammatory, and profibrinolytic properties. A clinical study has shown that the drug significantly reduced the mortality in severe sepsis although due to its antithrombotic properties, the patients are at a higher risk of bleeding (Bernard, et al 2001).Further studies are necessary to better understand the pathogenesis leading to sepsis. The knowledge gained in these studies which further enhance the development of newer drugs with better safety profile. In addition, more clinical trials are important to assess the drug efficacy of existing drugs so that better management of sepsis can be formulated to improve the morbidity and mortality of the disease.