“On the Sidewalk Bleeding” by Evan Hunter Essay

In the short story â€Å"On the Sidewalk Bleeding† by Evan Hunter, we learn that the main character of the story, Andy, is struggling to remove his jacket while he lay in an alley bleeding. We also learned that it was very painful for Andy to move, let alone take off the silk jacket, but he did so anyway. The jacket he wore symbolized his belonging to a city gang called The Royals. Andy wanted to remove his jacket in his last moments because he did not want people to think of him as being just another member of The Royals; he wanted to be remembered as Andy. Andy did not want to be portrayed as simply another young teenager who was caught up in city gang violence, but as himself; and so he tried to remove it. Andy knew that if he died, he would no longer be a Royal, but just simply Andy. While lying in the alleyway, Andy realized that the only reason a member of The Guardians, their opposing gang, stabbed him was because of his purple silk jacket that had the words â€Å"The Royals† stitched to the back of it. The words of his attacker continuously repeated in his mind; â€Å"That’s for you Royal!† Andy knew that the knife that cut through him did not hate Andy, but hated the jacket. Andy realized that the title of being a Royal was no longer as important to him as it once was. The jacket he had once worn with pride had meant nothing to him, and was the cause of the stabbing that occurred. Andy wondered why he thought the fights, the jumps and the purple jacket were once so important to him. While he was dying, he finally realized that being a Royal was not worth it because he had just wasted his time. Andy suddenly felt as though he had never done anything, seen anything or been anywhere. Although it was painful for Andy to remove the jacket, he did so in his last moments because he had realized how stupid being part of a gang was. Andy struggled to remove his jacket from his backside because he no longer wanted to be part of gang violence. Andy did not want to be a Royal.

Kung-Fu Panda 2 Belonging

In the film Kung-Fu Panda 2, the extended metaphor of â€Å"Inner Peace† in the film symbolizes the need for a person to acknowledge their own weaknesses, their past and their faults, which conveys the importance of finding and accepting one’s identity. Furthermore throughout the film, there are various scenes where water droplets are dropping and flowing in slow motion, combined with flashbacks of the past, demonstrates the power of spiritual connections and nature. The importance of belonging and loving your family is also emphasised in Kung-Fu Panda 2.Through the protagonist, Po’s, exploration of his true parentage, the power of common memories to influence the bonds between people is displayed. It is important to accept who yo9u are as it can affect where you belong and how you feel. When he questions his dad about his true parentage, saying he had a dream about his mother, his adoptive father, Mr. Ping, freezes and looks agitated, showing that he is scared t hat he will lose Po if the truth is revealed. Whenever Po questions his lineage, sad music is played, making the audience feel sympathy for Po’s turmoils.Even after all the events that happens throughout the film, Po comes home back to Mr. Ping he says to him â€Å"I know who I am now, I am your son, I love you dad. † While this is happening, there is soft and happy music playing in the background, showing that even though they aren’t blood related, they are still happy together. This is true belonging. Even though they have no blood relations, they are truly happy together and value each other’s company, showing that they belong together. This relates to belonging and accepting yourself.The importance of individuality in finding a role in society is emphasised heavily throughout the film. The film follows the growth of Po in his journey of achieving â€Å"Inner Peace†. In the film you see Po’s idolization of other Kung Fu legends displays h is own inner emotional insecurity and spiritual turmoil. This is also reinforced through the technique juxtaposition, shown through Po’s fatness and Tigress’s hardened self. The need for you to accept your true self in forming meaningful relationships is shown through this.It is shown through the dramatic irony of Po’s insensitive comment â€Å"I have to know, the hard-core wouldn’t understand† directed at Tigress, saying that she is unable to feel both physically and emotionally. The close-up shot of Tigress’s saddened and hurt face combined with the sad; non-diegetic music further incites the audience’s sympathy of Po trying to find out about his own individuality with Tigress stopping him. Throughout the film you also hear the metaphor of â€Å"Inner Peace† used excessively.The phrase â€Å"Inner Peace† means to be spiritually and mentally at peace, with enough knowledge to keep oneself strong when under great hardshi p and stress. Throughout the film, Po is plagued by nightmares of his past and his own insecurity compared to Tigress and the others. In the beginning, Po witnesses Master Shifu moving a droplet of water all over his body without it splashing or breaking its form. When Po inquires how he did this, Shifu responds by saying â€Å"Inner Peace†. It is implying that having inner peace allows you to do things that are impossible, which is also shown when Po catches a cannon ball and throws it back.In the film, having inner peace symbolises that you have accepted yourself for who you are, complete with strengths and weaknesses. By having inner peace, it is saying that you can achieve things that you couldn’t achieve before & to be able to find out where you truly belong. The director of this movie positions the audience to sympathise with Po through the demonstration of the fallibility of one’s memory, which is shown through the flashbacks and dramatic devices used as Po lies to himself. Po couldn’t accept his own self throughout the film, which draws in the audience to feel sorry and sympathise for him.The differing perspectives of Po and his companions are comically shown through his fights with them. However, the audience is positioned to support Po though the uses of Mise-en-scene, as screen elements’ visual size are diminished whenever Po is in the screen. As Po zooms towards the audience and takes the centre of the screen, it enables the audience to see things through Po’s perspective. At the end of the film, Po is hailed as a hero & feels that he has finally found that he has been accepted by Tigress and the others. He finally feels that he belongs.

Ambrose Bierce’s short story “Chickamauga” Essay

Ambrose Bierce’s Chickamauga is a disillusioned child’s awakening. Literally, a six year old deaf boy is thrown into a most horrifically traumatic series of events. His story is relayed in the third person omniscient perspective through the eyes of the child as well as an elder. It takes place during the Civil War in a southern town. Chickamauga begins with the boy’s entrance into the forest where he goes to play solitarily. With him he carries a toy wooden sword with which he battles imaginary enemies to their deaths. Lost in his adventure the boy grows tired and falls asleep between two rocks deep in the woods. While he is a sleep a battle occurs unbeknownst to him. Several hours later the child wakes up and notices alien figures crawling towards him. Without knowing the gravity of the situation occurring before his oblivious eyes, he makes a game of it all. The child assumes a leader position for what he has finally determined to be men, and guides them towards a red light. The red light turns out to be his house on fire. When the child finally reaches the fire he is particularly amused by the raging spectacle. He searches desperately for fuel and finally commits his toy sword to the fire. Suddenly the boy realizes that fire is his own home. Horrified he studies the ghastly scene. He then stumbles upon his brutally murdered mother. The small child gets extremely upset, and at this point the reader learns that child is a deaf-mute. The story can be divided into three essential stages, representational of the boy’s progression from innocence to forced maturity. The boy advances through innocence, progression to familiarity with reality, and awakening. The small child enters the forest joyfully and carelessly, he leaves with tremendous fear, depression, and realization. The forest is symbolic of middle ground between innocence and h orrible reality. The six year old enters the forest as an innocent child with no experience in reality. All of his days until this one have been a candy coated fantasy. He’s spent numerous hours reading and learning about the glories and fairy tale aspects of war with his father. This little boy was born into warrior-blood. All of his predecessors were soldiers including his father. He enjoyed learning about war. However, the fatal mistake of this six year  old little boy’s life was his active interest in combat. It was his interest which led him deep into the forest playing, battling fantasy foes. His fight, his game, his reality until this point in his life was fabricated. The reader gets a real sense of his naivety when he encounters a rabbit and is terrified. Maybe the child has never seen a rabbit before, or maybe he has seen one viewed in a dark light. All facts of this boy’s life until this fateful journey into the woods have been given to him. The knowledge he possessed was second hand; it seems as though he’d never experienced anything himself. His father had delivered all of the information the boy held through books, which ironically glorified war. This child’s tragic encounter with war was so foreign and inconceivable to him that when it so brutally hit him he doesn’t even realize it. The woods in Chickamauga symbolize the cruelty of reality. At his entrance into the forest, this completely innocent six year old begins his journey towards the horrors that await him. When the boy is in the forest he cries himself asleep, terrified of the new and unfamiliar paths he’s traveled. While he’s asleep a battle occurs and his house is set on fire. However the child is deaf so he does not hear what is going on. Finally he wakes up to see what look like animals, which in actuality are the soldiers retreating from the battle that has just occurred, and becomes innately curious. He did not understand what they were, he didn’t know whether they were dogs, horses, bears, he had no idea. As they got closer he â€Å"saw little but that these were men, yet crept like babies.† This fact intrigued him. As he inspected the men he laughed at their unfamiliar state, and related them to clowns he’d seen in a circus. Their bloody faces reminded him of the paint on the clowns’ faces. This optimistic association reveals his ignorance of what actually happened. He then recalled that at his home the Negroes had crawled on their hands and knees for his entertainment. He thought it to be a good, fun idea to attempt to â€Å"ride† one of the soldiers. The child gets a thrust into reality when he is thrown off the man and subsequently forced to see his mangled face. When the boy looks at the man he sees â€Å"a face that lacked a lower jaw–from the upper teeth to the throat was a great red gap fringed with hanging shreds of flesh and splinters of bone.† The reader gets a real sense of the child’s naivety when the child is only slightly  disturbed, as he had been with the rabbit. This forces the child to take a slightly more somber view of the situation. However even after this horrific encounter the boy is still fairly oblivious to what is happening. He witnesses death all around him. When the child sees the soldiers lying dead in the water, â€Å"his eyes expanded with wonder; even his hospitable understanding could not accept a phenomenon implying such vitality as that.† It was not in the child’s range of conception to even take in such horror. It is after this encounter with the garbled soldier that the boy catches sight of the red light which guides him to his miserable fate. After obtaining a more serious perception of the state of affairs, the boy positions himself as leader of the soldiers. It seems at this point that the child has gained some insight into reality from the grotesqueness of the bloody soldiers, but still significantly less than a more aware, less naive person would have acquired. This becomes apparent when the boy is at the fire and enjoys its flaring spectacle to no end. The boy is ecstatic and dances with the flames devouring his house. He even tries to fuel it. The boy searches around the yard for objects to throw in, all are too heavy. He is finally forced to surrender his sword. With his sword the child surrenders his innocence. Suddenly with no warning or cause the boy’s disillusion detonates and reality afflicts him. He realizes that the fire is his own house. Horrified at his abrupt realization the boy runs â€Å"with stumbling feet,† frightened at what he is witnessing. At this point he encounters his mother. He sees her with â€Å"the clothing deranged, the long dark hair in tangles and full of clotted blood. The greater part of the forehead was torn away, and from the jagged hole the brain protruded, overflowing the temple, a frothy mass of gray, crowned with clusters of crimson bubbles.† This is his final jolt that forces him to the rock-bottom, ultimate darkness of reality. This sight of his mother, probably raped, brutally murdered jerks him into shock. Traumatized, the young boy â€Å"moved his little hands, making wild, uncertain gestures. He uttered a series of inarticulate and indescribable cries.† This is his horrible awakening. Chickamauga is representational not only of the boy’s awakening, but of human awakening as well. The child’s initial entry into the forest is symbolic of  every journey we take as humans into the unknown. In the forest he acquired immense amounts of insight into what reality could be, but had trouble comprehending the severity of what he was witnessing. It was not until the trauma personally affected him that the small child was struck with what actually happened. This is parallel for most humans in their experiences with trauma. Trauma is real and depressing when it is witnessed personally by someone, but when it is inflicted upon someone we know or love it becomes so intensely real that it is impossible to grasp. This impossible conception is analogous to the small boy’s incoherent cries and gestures at the end. The theft of this child’s innocence was slow and unperceivable in the forest, but most definitely contributed to the final jolt the child felt at the end. The boy slowly progressed towards reality, and when it finally clicked it was appalling.

Should the Death Penalty be legal Essay Example | Topics and Well Written Essays - 1750 words

Should the Death Penalty be legal - Essay Example Those who are against the use of capital punishment do not think that the government should be given the authority to subject any of its people to death. They also say that this practice is overtly costly, racially partial and does not realize the intended result. The vast majority of Americans consider the death penalty to be neither cruel nor unusual, quite the opposite; they think it’s a fair and just punishment. They not only accept but stridently insist that the â€Å"ultimate punishment† be sustained for several reasons which will be thoroughly covered in this paper. It will also take into account the opponents’ logic concerning why it should be ended in an effort to show an inclusive summary of the contentious death penalty debate. History of Punishment Historically speaking, the justification for punishing offenders has been to â€Å"avenge the crime, to protect society by imprisoning the criminal, to deter that person and other potential offenders from the commission of crimes and to obtain reparations from the offender† (Wolfgang, 1998). All through the history of civilization, this rational has not altered appreciably. The four fundamental reasons humanity punishes criminals can be classified by two basic motivations. One is to obtain the desired outcome which includes protecting society, deterrence and seeking compensation. The other, retribution or vengeance involves reprimanding those who have committed a crime on society. For thousands of years people have subscribed to retribution as validation for using the death penalty which can be found in the Biblical reference ‘an eye for an eye.’ In other words, aggressive actions against society must be confronted with an aggressive punishment (Olen & Barry, 1996: 268). This use of any type of punishment is humanity’s method of striking back at a person or persons who have disturbed the ethical and emotional sensibilities of a society. The ‘eye for an eye’ justification continues to be used by many people and nations today. Those who embrace this viewpoint are undoubtedly correct when they state that capital punishment assures that the offender will not be able to commit another transgression against society. The death penalty is the definitive preventative measure (Olen & Barry, 1996). Opponent Position Persons who oppose use of the death penalty think that all life no matter how despicable should be considered of value and that putting a person in prison for life without the opportunity for parole is sufficient punishment. Opponents also believe that revenge as justification is wrong and in the end more harmful to the values of society than is the crime of murder itself. Additionally, opponents think that banning the death penalty will â€Å"allow opportunities for confronting those who had been hurt most and possibly encourage remorse or reconciliation (and) suggest those that have killed be made to service the commun ity as a way of partially making amends† (Olen & Barry, 1967: 272). According to opponents the death penalty is morally and ethically objectionable in modern society. Some are against it based on religious reasons referring to morality as the primary issue; however, differing religions and the faithful within those religions have conflicting opinions. For example, Christians who live in America overwhelmingly support it while Christians in Europe tend to oppose it. Legal Interpretations The U.S. Supreme Court has maintained that use of the death

Intelligence Collection Essay Example | Topics and Well Written Essays - 750 words

Intelligence Collection - Essay Example These vessels leave behind traces of chemicals while moving which are detected by sampling (chapter 11, page 238). 2. Materials acquisition refers to gathering a piece of component or equipment, such as a vehicle, an integrated circuit chip, radar or a missile. Two purposes of the process are reverse engineer a component and performance analysis of the equipment. During their glory days, the Soviets used to be excellent at concealed materiel acquisition. At a certain time they dealt with acquiring a latest IBM machine before it was formally launched in the market; but, the consequence was less than pleasing for the Soviets since none of the maintenance or sales staff of the firm they contacted afterward, didn’t know how to operate it (chapter 11, page 246). 3. Each nuclear detonation leaves evidences in the atmosphere. Nuclear forensic department presently implements 2 kind of collection. One is directed towards testing nuclear arms and evaluating its performance and depends on ground or aircraft sites to gather air samples. Another one is meant for detecting the movement or production of materials used in nuclear weapons and depends principally on gathering material samples near or in an anticipated milieu. The final kind of collection is promising but luckily has yet to be implemented: acquiring samples of the remains after a nuclear combat for the rationale of finding out the source of the device applied (chapter 11, page 240). Fingerprints are considered as principal biometric method, as it is evident that no 2 fingerprints are accurately same. Today, fingerprint readers have become widely available and inexpensive. Voice imitation that seems like a correct match to the individual ear would, rather, have a considerably diverse voice print. A sample of DNA can be studied to recognize either a DNA profile or a DNA fingerprint. Retinal scanning assesses the structure of blood vessels at the backside of the eyeball. Iris scans studies

International Relations Theorist With Their Theories And Provided Essay

International Relations Theorist With Their Theories And Provided Reading - Essay Example The theory adds that poor countries cannot achieve riches due to inadequate natural resources. A nation’s economic growth is limited in the case it runs out of financial resources such as fertile land. All the resources are termed as incapable of increasing productive capacities of an economy. Developing nations have excessive populations. The serious shortage of capital and land is common, and it leads to damaging implications. With lesser lands, cultivation encounters a significant fall in activities that are the major sources of income for poor countries. Farmers are not able to reap benefits of their inputs as lands are fragmented through government enforcement or inheritance to ensure social fairness in society. The other issue is acute levels of food shortage. These elements, as highlighted in Lewis Theory of Development model, hinder economic growth while leading to economic problems such as starvation. The second theory is Chenery’s Patterns of Development. The ideology illustrates those empirical analysts in structural change identify patterns of historical under-development against non-Western nations. The approach contrasts with Rostow’s application as they do not take the assumption that savings and investments increases are sufficient in producing economic growth. Even as savings and investment are perceived as necessary conditions for enhancing growth, alternative changes within the structures of any country are necessary for transitioning from traditional economies to modern ones.2 From this, lack of skilled human capital is a hindrance. Poor nations have minimal budgetary allocations to sectors of education and health.

Lateral Violence in the Emergency Department Dissertation

Lateral Violence in the Emergency Department - Dissertation Example The paper "Lateral Violence in the Emergency Department" talks about the lateral violence as an act of violence against ones’ peers and focuses on lateral violence in the Emergency Departments in the US healthcare system. The lateral violence has increased the prevalence of mental health conditions such as depression and schizophrenia among clinical nurses (Kathryn, 2011). When nurses are not happy their motivation and job satisfaction decrease. Eventually, these lead to higher employee turnover rates which increase the healthcare institution’s expenses and a shortage of staff. Most importantly, lateral violence among nurses has compromised the quality of healthcare service by reducing the levels of optimal patient care. Lateral violence has especially been identified as more prevalent among nurses working in Emergency Departments. There are cases where a nurse has noted an error in medication administered by a fellow nurse but because of lateral violence within that se tting that nurse fails to report this error, may be due to fear or revenge, this later leads to aggravated conditions for the patients. Many patients have experienced a relapse in their conditions because one nurse refused to help another nurse claiming to be too busy when their help was needed or sought. Most of the decisions and medications nurses in ED make determine whether a patient lives or dies. It is, therefore, crucial that the incidences of lateral violence between nurses working in the ED be kept at their minimum.

Capital structure of CVS Essay Example | Topics and Well Written Essays - 750 words

Capital structure of CVS - Essay Example Therefore, equity financing effectively increases the weighted average cost of capital. 3. Schedule out & calculate EVA. Is it good or bad and what brings EVA up & down for CVS There are various ways of measuring a firm's performance. One way is to use accounting measures such as return on equity, return on assets, etc. Another way is to use market measures and determine the firm's performance by looking at the stock's value. These measures, however, do not provide an effective evaluation of firm performance. One such measure that determines the true value-creating performance of a firm is Economic Vale Added (EVA) analysis. This analysis attempts to determine the net contribution to value by a company's investment decisions which other measures fail to provide. This means the after-tax returns of the company should exceed the cost of capital invested. EVA is calculated as follows: EVA = (ROIC - WACC) x Invested Capital Formula for Return on Invested Capital (ROIC): ROIC = Net Income / Liabilities + Shareholders Equity ROIC for CVS = 11.4% Invested Capital = market capitalization = 262,500,000 (common stock * share price) EVA for CVS is: 7,875,000 EVA is dependent on return on invested capital as well as the cost of capital. Higher ROIC and a lower cost of capital can increase EVA significantly. 4. Look at EVA & how do you need to change bank statements to create the best capital structure An EVA of 7,875,000 means this is the net contribution to value added by the company's investment decisions. Higher EVA can alter the capital structure by increasing the proportion of equity to debt. However, every company has a target in terms of maintaining... Weighted average cost of capital is the discount rate used to convert expected future cash flow into present value for all investors. Using the book value of debt and equity, CVS is 26.2% financed by debt and 73.8% financed by equity1. Cost of equity can be calculated using the capital asset pricing model. There are various ways of measuring a firm’s performance. One way is to use accounting measures such as return on equity, return on assets, etc. Another way is to use market measures and determine the firm’s performance by looking at the stock’s value. These measures, however, do not provide an effective evaluation of firm performance. One such measure that determines the true value-creating performance of a firm is Economic Vale Added (EVA) analysis. This analysis attempts to determine the net contribution to value by a company’s investment decisions which other measures fail to provide. This means the after-tax returns of the company should exceed the cost of capital invested. EVA is calculated as follows: Look at EVA & how do you need to change bank statements to create the best capital structure? An EVA of 7,875,000 means this is the net contribution to value added by the company’s investment decisions. Higher EVA can alter the capital structure by increasing the proportion of equity to debt. However, every company has a target in terms of maintaining an optimal capital structure that minimizes cost of capital and maximizes shareholder wealth. A higher equity and lower debt in the capital structure substantiates.

Basic Elements in Behavior Essay Example | Topics and Well Written Essays - 500 words

Basic Elements in Behavior - Essay Example The main parts of human body include heart, the nervous system and the most important is the brain. The nervous system is the main route which helps to carry all the information to other parts of the body. It has always been a mystery that how a human brain works although many scientists have conducted many theories about it. Moreover it has now become evident that the first five years of a person’s life are the most important in the physical brain development. The human body contains a huge number of neurons. It is said that approximately one trillion neurons are required to control the human behavior. Neurons are considered as the basic elements of human behavior because they not only help in achieving our day to day physical activities but they help us to think, move, remember and feel all the emotions. They are just like chip in a computer which is used to transfer information from one part to the other. As it is believed that there is something inside our body which contr ols all the actions. This thing which controls our actions is called Neuron. (Feldman, 2009, p. 114). Neurons are just like other cells of the body. Their body consists of a nucleus which tells that how the cell will perform its functions. Moreover the neurons have the ability of transmitting information to other neurons having long distances.

Reading More Books Essay Example for Free

Reading More Books Essay How to encourage your children to read more books Ten great ways to develop your children’s desire to read book By Chris Barnardo Reading is great for both you and your children and is a fantastic form of relaxation and escapism. Reading books helps your children develop their language skill, extend their vocabulary and their understanding of the world. Your children’s spelling and writing skills are also improved by regular reading. Reading can be especially helpful to your children when they are going through difficult times in their lives, such as the separation of parents,  starting a new school, the death of a loved one, bullying, or puberty. A good book gives them a mental place to go where the day to day worries aren’t so ever present, it gives them new people to meet and gets them involved in other people’s stories. Reading develops your children’s creativity. It’s better than the television, because when children get involved in the book they are reading, they imagine the characters and scenes, which paint all kinds of Fill your house with books and give your kids their own bookshelf This is especially important if they don’t live with  you, because any way you can make your place feel like their home, is good, and having their own favourite books in a special place is perfect. Read to your children Set up a routine of a bedtime story or chapter from their book. Bedtime reading is a great routine to get into because it is a perfect relaxing bridge between the excitement of the day and sleep. It is also a special time for you to be together without the stresses and hassles of the day, a time when all is clam and you are just having fun together. However, don’t restrict yourself to bedtimes,  read to them whenever the opportunity presents itself. Read them funny or interesting stories from the newspaper when you spot them, save and read out a funny or moving poem before you eat a meal together; get them to read their homework out loud to you when they have done it. Page 1 of 2 wonderful images in their minds, in a far more interactive and satisfying way than television can ever do. reading encourages your child to be creative and think for themselves. So, everyone knows how good reading is for their children, but how do you encourage them to read, or read more. Here are ten top tips to get you started and get your children reading books. Listen to audio books in the car on longer journeys Audio books make every long journey an adventure in itself. If the story is good and the narration is well done, the journey will flash by and when you reach your destination you may even find yourselves wanting to stay in the car to hear the end of the story. They can be expensive, but most stories will bear repeated listening and the library lend out audio books for free. Don’t be a book snob Children are inspired to read by all kinds of  different books, graphic novels, magazines, web blogs, manuals, science fiction, or teenage romance for example. Let them get interested in reading in whatever form that takes to start with, once they get into the habit of reading this will expand to take in a wider and wider choice of material over time as their friends introduce them to new books and ideas.  © C. Barnardo dadcando 2008 How to encourage your children to read more books Talk though the story when you read it Chat about the characters in the story. If it is a novel then talking about the main character’s  motivations, asking what your children think the characters are going to do next, or what is going to happen in the story, all add weight to the experience of reading. Ask questions about the writer’s style, or the way the writer describes the scenes will help your children get the most out of the story and will help them in a very subtle (but powerful) way with their own written schoolwork and homework assignments. Discussing stories and listening to what your children have to say about the characters and the situations they encounter in the book will tell you a lot about  what your child is thinking, and help you understand them better. At weekends or on holidays make a treat of getting magazines Magazines have short articles about things they like, horses, cars, fashion, gossip, TV soaps, toys, console games, and popular science for example. If they really like a particular magazine then consider buying a subscription to it for them as a birthday (or other special occasion) present. Give books as gifts Take the trouble to go to the bookshop at the weekend or browse the second hand book shop for interesting titles and involve your children in  choosing the best book as a gift. When giving a book, especially to your children, always write their name and the date and a short message in the book inside the cover or on the flyleaf. Then they’ll always know it’s theirs and know that you think that it is a precious gift that you have chosen specially for them. Choose material that they like There is plenty of time to discover the classics. To start with choose books that you know your children will like. Choose different books to read to them than those which they are going to read to themselves. When you read to them, you can pick books with exciting or thrilling stories that may have longer words in then they would be able to read themselves. (Always explain a word or phrase if you think that they don’t understand it). Perhaps you have seen a film that you all liked, get the book that inspired the film and read that. If they are reading to themselves, a graphic novel or even a comic is an excellent way to start reading around a film story. Have a word of the day Reading is as much about exploring language and the way stories are told as it is about the stories  themselves. Look on the web or in a dictionary and pick a word of the day which you can all learn together. The word you choose can be gross or exciting, different or funny, long or strange but above all make sure that it is useful in some way. Get everyone to make up a sentence with the new word in it and give a point or star for the best sentence. If they want, let your children each find and tell their favourite new word of the day. A good time to do this is at meal times when you are all together. *** For some ideas on a few good books that your  children might like, have a look at dadcando’s what we like this week column or dadcando’s recommended â€Å"Superb kid’s books† on dadcando’s â€Å"Be Inspired, be inspiring† pages. Get a poetry book and occasionally read them a poem Poems are fabulous for evoking emotions and feelings. The best poems condense and capture descriptions of scenes or feelings in a very powerful way, bridging the gap between stories and songs. Inspire your children with poems and they will remember lines from them, and the times you read to them, for the rest of their lives. Page 2 of 2  © C. Barnardo dadcando 2008.

Dengue Fever and Malaria in Thrombocytopenic Patients

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