Auditing Essay Example | Topics and Well Written Essays - 2000 words - 4

Auditing - Essay Example Audit risk refers to anything that will prevent ABC Chartered Accountants from giving a correct and an appropriate audit report about Zebra. Inherent risk involves the risk that the operations of Zebra within the period had issues that could lead to material misstatements or errors (Collier and Agyei-Ampomah, 2010). This will include the risks that staff members and managers in Zebra can conduct certain fraudulent or wrong activities in course of the operation of the company. The obvious inherent risk involves the pressures and changes that occurred in the period. The obvious increase in the credit period which gives external entities access to funds meant for Zebra and this causes an extended lock up of capital which could lead to the significant defaults and losses to the company. There is also the risk of staff members overstating their earnings and their sales in order to gain the commissions that have been offered. Finally, the pressure to join the Australian Stock Market provides the risk for Zebra staff members to overstate the asset position in order to attain a favourable view before various investors and the Au stralian public. Control risks involve the possibility that the controls put in place by Zebras management and directors will be overridden in a way that could lead to fraud or errors in the financial statements (Pickett, 2010). This involve the risks of the EFTOS system being abused by some parties in the company to lead to fraud and error. Secondly, the risk of people overstating their sales and indulging in unethical practices plays a significant role in overriding the systems. Additionally, the management of Zebra could override the systems if they all indulge in groupthink and they all second the need to get listed to expand the firm. This could lead to major problems and issues that can involve the complete disregard for internal controls. Detection risks is the possibility of ABCs

Literary Theme Essay Essay Example for Free

Literary Theme Essay Essay The Privilege of Freedom â€Å"Only the educated are free.† Said by Epicetus, this simple quote demonstrates the importance of education. A solid education will provide for an excellent future and give one freedom: freedom to take on a career, to jump at opportunities, and to make choices. There is no saying where the future might take an educated man. Dangarembga uses highly educated and successful characters to illustrate the privilege of education and the power, control, and freedom that it provides. Dangarembga shows that education can change a life for the better by presenting the main character, Tambu, with the privilege of attending an outstanding school. When Tambu is given the opportunity to live with her uncle and go to the mission school, she is thrilled to become educated. Before her brother died, â€Å"the needs and sensibilities of the women in† her â€Å"family were not considered a priority,† and school was not an option for her (Dangarembga 12). Education has provided Tambu with the privilege to escape her old life on the homestead and â€Å"take another step upwards in the direction of† her â€Å"freedom† (Dangarembga 186). Also, education has given Tambu the power to use her education to control the rest of her life. â€Å"By the time she has finished Form Four,† she â€Å"will be able to take† her â€Å"course, whatever it is that† she chooses (Dangarembga 183). â€Å"In time,† she â€Å"will be earning money,† which will then lead to a career and onto the rest of her life (Dangarembga 183). The wealth that Tambu will earn when she is successful will provide for her and her entire family. Education builds the foundation of Tambu’s future, and â€Å"the prospect of this freedom† is unlimited (Dangarembga 186). The character, Babamakuru, is used by Dangarmebga to demonstrate that one educated relative effects an entire family. Education is â€Å"not just an individual blessing† but one that extends to all members of a â€Å"less fortunate family† (Dangarembga 89). For example, Dangarembga shows that one educated man can support the whole family. Babamakuru, â€Å"who had obtained a Bachelor’s Degree in South Africa,† is extremely generous and provides resources and opportunities for his entire family (Dangarembga 13). Whenever Babamakuru goes to visit the homestead, he comes bearing food, gifts, and supplies for the family to thrive off of. Also, Babamakuru is responsible for Tambu’s education and her coming to the mission school. To Tambu’s family, â€Å"Babamakuru was God†, â€Å"big brother to all†, and â€Å"his divinity† filled them â€Å"with awe† (Dangarembga 70, 36, 88). â€Å"As an early educated African,† Babamakuru has â€Å"found himself in positions that enable him to organize his immediate world and its contents as he wished† (Dangarembga 88). His great power has insulated him â€Å"from the necessity of considering alternatives unless they were his own† (Dangarembga 88). Education has given him opportunities that have led to great power and control over others; nobody â€Å"dares to challenge his authority† ((Dangarembga 117). Without a well-educated, successful man like Babamakuru, Tambu’s family would not be as the same. Throughout Nervous Conditions ¸ Dangarembga exemplifies the key role that education plays in becoming wealthy and successful. The basis of a good future begins with education. Such a privilege can lead to so many new things, and when one is educated, the possibilities are endless. Works Cited Dangarembga, Tsitsi. Nervous Conditions. New York: Seal, 1989.

Mutual Trust in Employment Contracts

Mutual Trust in Employment Contracts Introduction In all the employment contracts a term mutual trust and confidence which is also known as the duty to act reasonably and fairly is implied or not is the question for over the past years. As per the labor regulations in Australia, different range of sources provides different rights and responsibilities of employers and employees, which also creates a huge different level of complications while going through these sources. These terms will generally be implied in an employment contract in Australia that has been widely acknowledged, but at the same time the debate on awarding the damages for a breach of these terms in some of the Australian courts will be challenging as well. Contract Contract is a legal document that states and explains a formal agreement between two different people or groups, or the agreement itself.[1] There are two kinds of contract and they are Express and Implied contract. Express contract is a type of contract which parties state the terms either orally or in writing at the time of its formation. On the other hand implied contract is a contract where terms and condition are not expressly defined at the time of its formation.[2] Employment Contract Employment contract is a category of contract, which used in employment. It is a relation between both parties on the one and stands an employee who is employed by an employer. It contains all terms and condition regarding employment.[3] Mutual Trust and Confidence in Good Faith Analyzing the concepts is very much necessary when it comes to â€Å"breach of mutual trust and confidence† and â€Å"the duty of mutual trust and confidence†. There is a lot of difference between the duty of good faith and the mutual trust and confidence. One talks about the implied duty that will relate to the terms of the contract and the relationship and whereas other talks about the incident of the employment relationship (right to Control). [4] When it comes to incident of the employment relationship, there comes a question whether the relationship of trust and confidence exists or not. Which totally depends on the nature of the employment. So there is a doubt that it has existed and continues to exist, a necessary relationship of trust and confidence between employer and employee. In an employment relationship the subsistence of mutual trust and confidence is very much essential to it. Because the employer cannot accept disloyalty of an employee who has undermine the employer’s business interest.[5] So the employee should not remain with the employer in employment because the employee has destroyed the trust and confidence in the working relationship. Employee’s destruction of trust can be evidenced by different types of conduct and which also depends on the circumstances of the employment. Some of the examples of different types of conduct, which may destroy the trust and confidence, are: demotion;[6] unwarranted carping criticism;[7] withdrawal of employment benefits.[8] It was first originated from the series of cases in the United Kingdom, in which employees totally blame employers for termination of their employment; despite this employers did not expressly dismiss these employees.[9] If any employee can make out that the employer’s conduct was so destructive of mutual trust and confidence, which properly ties up the parties to an employment relationship, than the employee treats employer’s conduct as constructive dismissal. In terms of contract law, employer’s conduct is treated as a repudiation of the employment contract by the employee as they are permitted to do so and elects to terminate the contract and claim damages for wrongful dismissal. On this basis in many of the cases, employee was seeking to claim statutory compensation for termination under the Employment Rights Act 1996 (UK) c 18.[10] Into the English employment law, duty was cemented by the decisions of House of Lords for example in Malik v Bank of credit and Commerce International SA (‘Malik’).[11] This was actually the test case for determining whether the breach of the duty is not to destroy mutual trust and confidence that could sound in damages. So it was held that mutual trust could sound in damages during employment as a consequence of the employer’s breach, that is why following this decision, not to destroy the mutual trust has been engaged to address a wide variety of claims. For example, in Clark v Nomura International Plc[12] and Clark v BET plc[13] So in the development of this duty in English law, which actually came from the decisions of a majority of the House of Lords that breach the common law duty of mutual trust, good faith and fair dealing would not sound damages until the damages flow from only the termination of the employment relationship. So to overreach the limitations already determined by statute,[14] the House of Lords held the common law not to be developed. Since in the United Kingdom the legislation has already imposed a cap on damages for termination of the employment, and also exercising the common law jurisdiction should not award damages that exceed the statutory limits for termination. To compensate for any losses incurred by the employee, damages might be awarded as a consequence of breach of employment contract during employment, but also not for any loss surffered as a consequence of loosing the job.[15] English scientific study of law has allowed damages for breach of the obligation that is not to destroy the trust and confidence, but even not when the damage flowed from the fact or manner of dismissal. Most importantly, in the English Law ‘the giving of the lawful notice cannot itself constitute a breach of the implied term.’[16] When it comes to Australian case law it has generally assumed that duty has been existed not to act in a manner or likely to destroy the mutual trust and confidence when it comes to employment relationship,[17] though no appellate court decision has depended upon such a findings.[18] Both parties to an employment relationship bear the duty not to destroy the mutual trust and confidence has assumed by the Australian courts in more recent times. When it comes to the English law, destruction of mutual trust signifies to the situation in which employees refuses to do something that are legally required to do as per employment contract and than identifies who is to be blamed if termination of the contract ensues. But whereas in Australian law, destruction of mutual trust and confidence has not been found to sound any damages on its own. In Australian case law it distinguishes between the employment relationship and employment contract.[19] The employment relationship is nothing but the actual dealing between employer and employee regulated by different types of law that includes common law of contract and also statutes that impose the mandatory obligations on the parties.[20] Whereas in terms of employment contract it is not automatically terminated when there is dest ruction of relationship of trust, but by electing innocent party.[21] In such circumstances the employees who gets terminated are entitled to be paid any remuneration or some other benefits according to his or her loss of account of premature termination of the employment contract.[22] This also means the payment of remuneration and other benefits that would have been received during a proper notice period. More importantly, the obligation not to destroy the mutual trust does not constrain an employer to take the decision to terminate the employment. So as long as the employer brings together the terms of the contract, and without prior notice and explaining how it should be done the employer is not at all liable for breaching the employment contract simply by deciding to terminate the employee.[23] Australian law has not gone so far unlike the English law, where the obligation is not to destroy mutual trust and confidence with a general duty of good faith and fair dealing in the employment contracts, in which breach might sound in damages. In some of the Australian cases there are few suggestions that on one hand there is two obligations of mutual trust and confidence, and on other hand the good faith, are having nearly the same meaning and these statements tend to be made by the courts who have found to decide upon the matter without any obligations.[24] According to Russell (Appeal) in 2008 â€Å"Although there were said to be two implied terms, it is probably sufficient to identify them as a single obligation.† [25] They derive from the same source, as siblings, that show the existence of a relationship of employment but again to understand it in the better way make it the separate concepts of each of them and with different functions. It is just a matter of choosing a vocabulary to assist in the clear articulation of separate concepts. The terminology of ‘mutual trust and confidence’ is very useful to describe in a particular characteristic of an employment contract that distinguishes it from a contract of sale or other contractual arrangement. Also ‘good faith’ is described as governing principle that is best engaged in interpretation and construction of relational contracts such as employment. Commonwealth v Barker It was in the year 2009 where the Commonwealth Bank of Australia took a step forward to change its Corporate and Financial Services business unit, due to which Mr. Barker’s position in the Bank was removed. As per the policy of the company, if they don’t require any position of the employee they will need to place that concern employee to the other part of the department or other position in the company. But in the case of Mr. Barker the Commonwealth Bank did not imply this policy. On 2 March 2009 Mr. Barker was send a letter to inform him about the redundant of his position but the Bank would like to send him to other area of the Bank. Later there was a meeting where Mr. Barker was told to clear out his desk, give away the keys and mobile phone and not to come to work. The Bank also stops Mr. Barker’s email and intranet facilities. On 9th April 2009, Mr. Barker was sent a letter of termination due to his redundancy and there was no sign of redeploy for Mr. Barker by the Bank. Mr. Barker had given his 23 years in the Bank and his contract of employment showed that he would be terminated only if the Bank is unable to give him a different position but there was no proper word in the contract apart from potential operation of an implied term of mutual trust and confidence. Mr. Barker’s file the case to the trial judge against the Commonwealth Bank and that included the failure of the Commonwealth Bank to give him the employment in some other department of the Bank.[26] What the Bank did to Mr. Barker was not according to the term of the contract of employment. As per the contract there should be mutual trust and confidence between employer and employee but that didn’t work at his time his employment. The policy of the company for redeployment was not utilized at his case of redundant of his position. Mr. Barker was entitled $300,000 from the bank for not following the company’s policy of redeployment. The case was then requested to the Federal Court as the Bank felt the Trial judge has made mistake in giving justice without any proper evidence. The courts refused to accept the appeal as Mr. Barker was more favorable and for this reason Jacobson and Lander JJ were appointed to go through the case in detail under Australian Law. [27] They came to the conclusion on the following grounds: In the court of England the policy support the implied term with the contemporary employment relationship.[28] The employment relationship should take part necessary of common interest and partnership fairly than a serious disagreement or argument.[29] These typical parts called for the result of an action or a decision by law of an obligation, for which employment relationship need to be in its original state.[30] According to the majority, the implied term only work in a particular way in respect of conduct and form a unit by it from the manner of termination of the contract of employment that is, it does not apply at the point of dismissing someone from their job or to steps inextricably linked with dismissal.[31] It was easy to see or understand from their reasons for decision that Jacobson and Lander JJ held that the implication of the implied term by law was necessary For Jacobson and Lander JJ, the Bank’s failure to give redeployment policy was not the important factor. As they found the Bank has not implied term or made something happen: Mr. Barker was a senior employee and worked for more than 23 years. The Common wealth bank was a large corporate organization and The contract (clause 8) contains that the employment may be terminated if the Bank were unable to place the employee in other position.[32] In these conditions of the facts, Jacobson and Lander JJ held that the implied term required the Bank to take positive steps from 2nd March 2009 to advice Mr. Barker about the possibility of redeployment and to give him the option to apply for alternative position within the Bank. [33] Jacobson and Lander JJ confirmed that Mr. Barker has been gone through hurt and distress and even loss of reputations that can never be recovered.[34] As an alternative reason for holding the Bank was liable, Jacobson and Lander JJ found that the same circumstances triggered the operation of the implied tasks of the organization in the contract of employment.[35] This implied the state of being forced upon the need for one party to take positive steps without which the other party is unable to enjoy a right or to be in a better position because of the contract.[36] By comparing the case where an employee despite to be knowing for the benefit unless it is brought to his attention by the employer. [37] After paying great attention to details and had judgment in which he completely study the gradual development of English and Australian case law in relation with the implied term of mutual trust and confidence, Jessup J concluded that: â€Å"the question whether the implied term is part of the law of contracts of employment in Australia has never been answered in the affirmative by an Australian appellate court in the sense of being of the ratio decided.†[38] His Honor went onto hold that the implied term of mutual trust and confidence was not needed for the pleasure of the rights conferred by the contract of employment.[39] Jessup J described the implied term as having â€Å"the potential to act as a Trojan horse in the sense of revealing only after the event the specific prohibitions which it imports into the contract.†[40] His honor makes a decision that the implied term, if accepted, â€Å"would enable defined limits in the existing fabric of common law and equitable remedies to be side-stepped†; and that the implied term would â€Å"overlap a number of legislated prohibition and requirements, thus tending to compromise the democratically-drawn architecture† by closely connected with the employment obligations.[41] Jessup J further held that the fact of being express reservation in the Bank’s redeployment policy â€Å"did not †¦leave any scope for the conclusion that by merely failing to comply with the policy, the Bank breached the implied term.†[42] The largest part of the case was in favor of Mr. Barker and at least for now, that in the period of time when express terms to the contrary is away, there is an implied term of mutual trust and confidence in every Australian employment contract. The decision moved to a higher level for consideration if the employers should clearly deliberate the implied term from employment contract. To whatever degree, it won’t be too complicated as given: As far as possible giving particular attention to the implied term, and The way of dealing by the majority judges, that particular circumstance triggered the operation of the implied term. The majority decision is turned upside down by the High Court of Australia on appeal; employers now need to put the implied term of mutual trust and confidence and the implied duty of cooperation to their list for them to remember all the time. In addition to the matters such as rise in the adverse action claims in dealing with their employees. When it comes to advantages and disadvantages for employers and employees of having such an implied term in the employment contract, employees should always remain faithful and sincere to the employer’s interest. Any confidential document or information of the company should not be shared outside the workplace to its competitors and it should remain internal within the workplace.[43] Whereas employers make decisions from the policies so they have to pay extra attention to its policies and regulations. In Barkers case federal court advised the employers to conduct themselves in a way that it wont destroy their relationship of trust and confidence with employee. When it comes to common law employers have to make sure that workplace is a safe place for employees to work. Employees have a huge advantage in having the implied term mutual trust and confidence because if there is a severe breach in the employment policies which is found than through the award of damages by the court, it will not only be considered a breach of an implied term. Conclusion In my view the term mutual trust and confidence is very much important to be implied in the employment contract. Because having the term mutual trust and confidence in the contract will create a comfortable working environment and also conditions can be achieved between both employer and employee. Incase if such implied term is not reflecting in the employment contract than either the employer or the employee would be permitted to act in a way that is not necessarily in accordance with the will of the contract. And also the practice of obeying rules between employer and employee are included in the viewpoint of an implied term. [1] Cambridge Advance Learner Dictionary (3rd Editioin) [2] ibid [3] Mark Freedland, the personal employment contract 2003 Oxford University press. [4] Gillies v Downer EDI Limited [2011] NSWSC 1055 [5] Concut Pty Ltd v Worrell (2000) 176 ALR 693. [6] Russian v Woolworths (SA) Pty Ltd (1995) 64 IR 169. [7] Lewis v Motorworld Garages Ltd [1986] ICR 157. [8] Clark v Nomura International plc [2000] IRLR 766. [9] Courtaulds Northern Textiles Ltd v Andrew [1979] IRLR 84. [10] Lewis v Motorworld Garages Ltd [1986] ICR 157. [11] [1998] AC 20. [12] [2000] IRLR 766. [13] [1997] IRLR 348. [14] Johnson v Unisys Ltd [2003] 1 AC 518, 544 [56]–[58] (Lord Hoffmann). [15] Gogay v Hertfordshire County Council [2000] IRLR 703. [16] Kerry Foods Ltd v Lynch [2005] IRLR 680, 682 [16] (Clark J). [17] Sappideen et al, above n 10, 162 [5.230] and the cases cited there. [18] Aldersea v Public Transport Corporation (2001) 3 VR 499. [19] Visscher v Giudice (2009) 239 CLR 361. [20]Byrne v Australian Airlines Ltd (1995) 185 CLR 410. [21] Visscher v Giudice (2009) 239 CLR 361. [22] Thomson v Orica Australia Pty Ltd (2002) 116 IR 186. [23] Russell (Trial) (2007) 69 NSWLR 198; Rogan-Gardiner [2010] WASC 290 (22 October 2010). [24] Russell (Appeal) (2008) 72 NSWLR 559, 567 [32], [25] ibid [26]Barker v Commonwealth Bank of Australia[2012] FCA 942 (3 September 2012). [27] 2013] FCAFC 83 at para [79], [28] 2013] FCAFC 83 at paras [94]-[95], [29] [2013] FCAFC 83 at para [81], referring to the Full Court of the SA Supreme Court decision inSouth Australia v McDonald(2009) 104 SASR 344 [30] [2013] FCAFC 83 at paras [72], [107]. [31] [2013] FCAFC 83 at paras [72], [97]. [32] [2013] FCAFC 83 at paras [110]-[111]. [33] [2013] FCAFC 83 at paras [112], [117], [130]-[132]. [34] 2013] FCAFC 83 at paras [152]-[158]. [35] 2013] FCAFC 83 at paras [118]-[128]. [36] 2013] FCAFC 83 at para [122]. [37]As in the House of Lords decision inScally v Southern Health and Social Services Board[1992] 1 AC 294, discussed by the majority inBarker[2013] FCAFC 83 at paras [114]-[115], [123], [128]. [38] 2013] FCAFC 83 at para [280 [39] 2013] FCAFC 83 at paras [288]- [295], especially paras [289]-[290]. [40] 2013] FCAFC 83 at para [340]. [41] 2013] FCAFC 83 at para [340]. [42] [2013] FCAFC 83 at para [351]. [43] Ansell Rubber Co Pty Ltd v Allied Rubber Industries Pty Ltd (1967) VR 37.

Analytical Interpretation of Snow White Essay -- Snow White Analysis E

An Analytical Interpretation of â€Å"Snow-White†   Ã‚  Ã‚  Ã‚  Ã‚  Throughout the story of Snow-White, Competition is played out in numerous ways. As the famous saying goes-only the strongest survive and to the victor go the spoils. There were a few power struggles going on even under the primary plot. This is one way to describe some of the seemingly bizarre or extreme motivations that push the story to a grisly, but happy ending.   Ã‚  Ã‚  Ã‚  Ã‚  The first queen apparently dies in childbirth (but do we really know this for sure?) and is replaced with a new queen in order to re-establish the king’s dominance over his kingdom. How can his empire be complete without a queen, considering the king was now a single parent as well? His life as a widower could not last in a time when meeting the status quo was so closely tied to the validity of self. He had to have a wife if he already had a child. Quite possibly, the king was influenced by outside forces to re-marry, or simply did not want to have sole responsibility of raising Snow-White and took another wife to safe face.   Ã‚  Ã‚  Ã‚  Ã‚  The battle between Snow-White and her step-mother was demonstrated to extreme ends. It was contested from both sides. The lack of action on Show-White’s part is an action in itself. Her passivity was an act of rebellion and self-preservation. I believe that Snow-White was far more manipulative than the story gives her credit for. Regardless of the initial chaos in any situation that the girl found herself in, especially th...

As I See Myself (Descriptive Essay)

AS I SEE IT My name is Katrina but I prefer to be called as Kat. At my current young stage, I have an average height of five feet, three inches however I weigh heavier than any other girls of my age. By nationality and by blood, I am a Filipino. I have had dark straight hair which is already dyed with golden blonde, brown eyes which I genetically inherited from my mother, a short nose, small gleaming teeth, full lips, tiny dimples and a round face which I am teased a lot by many people as well as my big fat arms.Nevertheless, I am proud of having a fair skin; long thick hair just like of a commercial model as what my sister would say; and long solid legs. So, I usually wear not-so-short shorts and skirts paired with t-shirts and flats. Like many girls, I like to dress up but then I don’t really have many clothes to dress up with so I end up with the basics. I also like my hair loose and undone because I like better messy hair, in a structured way and in a way to conceal my hug e face. I used to be very shy and introvert when I was little.I don’t talk unless someone starts a conversation and sometimes I don’t ask questions to keep the discussion going. But now, I develop some confidence and courage to express my thoughts and feelings; I feel more comfortable when I’m alone with someone I’m not used to be with; and I can already look straight to their eyes. I am an ineffective liar. When I start to lie, I tend to laugh. The more I try to get serious, the more I easily burst out into laughter and normally, I can’t keep eye contacts with them.I am also an ineffective joker because frequently I end up laughing first before I could tell my joke. That’s me, making most of my time happy and laughing because I love what it brings me and I love hearing the sound of glee. But sometimes, a different me comes out particularly when I am treated impolitely and when I am force to wake up. Then again, I come back to my usual self once I’ve realized I’m being mean. I am also a person who likes to try new things or should I say adventurous and risk-taker which are the traits I get from my father.When it comes to this, I behave surprisingly energetic and enthusiastic. I can also be lazy at times especially when I don’t like what I’m supposed to do otherwise, I voluntarily do things in the best way I can. I was born a very grumpy girl indeed. What’s more, I am a very ambitious person. Ten years from now, I could see myself as a successful and refined CPA having established my own business, a house that I designed myself since I also dream to be an interior designer and cars that I never thought I would have.I intend to continue my profession, enhance my skills and to be a good public servant too. Given that I am an adventurous person, I could also see myself as a wanderer who travels to the most wonderful and romantic places in the world just as I would picture in my mind every single day. As well as a loving wife and mother nurturing her wonderful family. I know gaining these things are hard to achieve that is why I plan on working harder in the present for a better future.

Pediatric Dengue Shock Syndrome Essay Example

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