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Happiness is the successful state of life, pain is an agent of death. Happiness is that state of consciousness which proceeds from the achievement of one’s values. A morality that dares to tell you to find happiness in the renunciation of your happiness—to value the failure of your values—is an insolent negation of morality. A doctrine that gives you, as an ideal, the role of a sacrificial animal seeking slaughter on the altars of others, is giving you as your standard. By the grace of reality and the nature of life, man—every man—is an end in himself, he exists for his own sake, and the achievement of his own happiness is his highest moral purpose.

But neither life nor happiness can be achieved by the pursuit of irrational whims. Just as man is free to attempt to survive in any random manner, but will perish unless he lives as his nature requires, so he is free to seek his happiness in any mindless fraud, but the torture of frustration is all he will find, unless he seeks the happiness proper to man. The purpose of morality is to teach you, not to suffer and die, but to enjoy yourself and live.

Galt’s Speech, , 123

Happiness is not to be achieved at the command of emotional whims. Happiness is not the satisfaction of whatever irrational wishes you might blindly attempt to indulge. Happiness is a state of non-contradictory joy—a joy without penalty or guilt, a joy that does not clash with any of your values and does not work for your own destruction, not the joy of escaping from your mind, but of using your mind’s fullest power, not the joy of faking reality, but of achieving values that are real, not the joy of a drunkard, but of a producer. Happiness is possible only to a rational man, the man who desires nothing but rational goals, seeks nothing but rational values and finds his joy in nothing but rational actions.

Just as I support my life, neither by robbery nor alms, but by my own effort, so I do not seek to derive my happiness from the injury or the favor of others, but earn it by my own achievement. Just as I do not consider the pleasure of others as the goal of my life, so I do not consider my pleasure as the goal of the lives of others. Just as there are no contradictions in my values and no conflicts among my desires—so there are no victims and no conflicts of interest among rational men, men who do not desire the unearned and do not view one another with a cannibal’s lust, men who neither make sacrifices nor accept them.

Galt’s Speech, , 132

In psychological terms, the issue of man’s survival does not confront his consciousness as an issue of “life or death,” but as an issue of “happiness or suffering.” Happiness is the successful state of life, suffering is the warning signal of failure, of death. Just as the pleasure-pain mechanism of man’s body is an automatic indicator of his body’s welfare or injury, a barometer of its basic alternative, life or death—so the emotional mechanism of man’s consciousness is geared to perform the same function, as a barometer that registers the same alternative by means of two basic emotions: joy or suffering. Emotions are the automatic results of man’s value judgments integrated by his subconscious; emotions are estimates of that which furthers man’s values or threatens them, that which is him or him—lightning calculators giving him the sum of his profit or loss.

Previous studies examining the etiology of CAP have provided widely differing results. Comparison is hampered by inherent epidemiologic differences in addition to lack of uniform inclusion criteria, study settings, and diagnostic methods. Despite rigorous attempts to identify a microbial etiology, 30%–64% of patients remain undiagnosed [ 3–12 ]. Studies applying molecular methods such as polymerase chain reaction (PCR) have yielded detection rates up to 86%, but highly specific patient selection criteria designed to optimize sample collection make comparisons difficult [ 13 ]. There is a dearth of population-based observational studies with high inclusion rates examining pneumonia incidence and etiology while avoiding overly selective inclusion criteria and applying modern diagnostic methods.

The aim of the present study was to prospectively investigate the frequency and etiology of CAP in a defined population, allowing for calculation of incidence, applying modern diagnostic tests, and comparing etiology with symptoms, risk factors, and outcomes.

This study took place at Landspitali University Hospital in Reykjavik Iceland (LUH). The LUH provides secondary care for the inhabitants of Reykjavik and nearby towns, comprising 63% of the national population. It also provides 90% of all intensive care in the country. Adults (≥18 years) admitted from December 1, 2008 to November 30, 2009 were screened for inclusion. Inclusion criteria were a new chest x-ray infiltrate and ≥2 additional symptoms: temperature >38.3°C or <36°C, diaphoresis, chills, new cough, chest pain, or new onset of dyspnea [ 6 , 14 ]. Exclusion criteria were as follows: admission to an acute care facility during the preceding 14 days; use of immunosuppressive medications (corticosteroids equivalent to ≥10 mg prednisolone daily, methotrexate, hydroxyurea, adalimumab, infliximab, etenercept, azathioprine, mycophenolate mofetil, or cyclosporine); ongoing treatment for a malignancy; receipt of a solid organ transplant; or human immunodeficiency virus infection.

Potential participants were approached within 24 hours of admission and underwent a structured interview, and data were collected on underlying diseases, subjective symptoms, and antimicrobial use before admission. Pneumonia severity index (PSI) and CURB-65 scores were calculated [ 15 , 16 ]. Outcomes were: length of stay (LOS), admission to intensive care units (ICUs), assisted ventilation, and in-house mortality. Outcomes were obtained retrospectively from patient charts. Vital status was cross-checked with national registry data after discharge from hospital.

The study was noninterventional but included additional diagnostic sampling. Sputum and blood were obtained for culture prior to in-hospital antimicrobial treatment and urine antigen testing was performed. An oropharyngeal swab was collected for PCR analysis. Results from physician-ordered etiological diagnostic testing were also included.

Furthermore, our diabetic patients, although normotriglyceridemic in the fasting condition, were also characterized in the postprandial period by a significant increase in the number of endogenous large VLDL particles, as reported in other studies ( 4 , 5 )

In healthy individuals insulin secretion increases in the postprandial phase, leading to a reduction in the secretion of VLDL by the liver ( 2 ). This allows normal handling of the intestinally derived lipoproteins, which share a common catabolic pathway through LPL with liver-derived lipoproteins. In our type 2 diabetic patients, even with fasting normotriglyceridemia, there was, instead, a substantial increase in the endogenous VLDL fraction during the postprandial phase, as indicated by the significantly higher incremental area of apo B-100 in large VLDL. As postprandial insulin response in our diabetic patients was higher compared with controls, it is likely that the increase in endogenous large VLDL is explained by a reduced inhibitory effect of insulin on VLDL secretion, as shown in the fasting condition ( 22 ).

At odds with data reported in the literature ( 4 , 5 ), the increase in chylomicron apo B-48 after the meal was not particularly evident in either diabetic or controls subjects. As people from southern Europe are characterized by an earlier apo B-48 postprandial response ( 23 ), it is possible that by taking our first sample 2 h after the meal, we missed an earlier apo B-48 increase. In any case, at variance with other studies, postprandial chylomicron apo B-48 levels in our diabetic patients were not different from those in control subjects. Our patients had a mild type 2 diabetes in optimal blood glucose control, whereas increased synthesis of chylomicrons has been reported in diabetic patients with unsatisfactory blood glucose control ( 24 ).

The triglyceride and especially the cholesterol content of chylomicrons were increased in our diabetic patients, especially in the late postprandial phase. It is of note that the cholesterol content remained significantly higher in the postabsorptive period as shown by the significantly higher levels observed in the fasting condition before the test meal. This enrichment in cholesterol of chylomicrons, which could be due to a higher activity of cholesterol ester transfer protein in the diabetic patients ( 2 ), may give more atherogenic properties to these large particles ( 8 ).

Together with the increase in the number of hepaticderived large VLDL, our diabetic patients were characterized by an increase in the number of chylomicron remnants, as shown by the increase in the apo B-48 incremental areas of large and small VLDL as well as by the lesser decrease in IDL apo B-48. These results may be due to different mechanisms, i.e. a deficit in LPL activity and/or an impairment in the hepatic uptake of these particles ( 10 , 25 ) as well as increased secretion of smaller chylomicron particles. We tried to evaluate more in depth the possible role of lipolytic enzymes, measuring both the activity of postheparin LPL 6 h after the meal and the basal preheparin activity of LPL throughout the entire postprandial period. The postheparin levels were very similar between diabetic patients and control subjects, whereas LPL activity without heparin stimulation was, if anything, increased in the diabetic patients.

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