Glycaemic Control for Type 2 Diabetes

Glycaemic Control for Type 2 Diabetes Case study 1: Glycaemic Status A newly diagnosed type 2 diabetic patient attended his outpatient appointment and reported that he had been tightly monitoring his glycaemic control. The biochemical analysis produced the following results: Value Range [Plasma Glucose] fasting sample 12 mmol/l 4-6 mmol/l Urea 10.1 mmol/l 3.3-6.8 mmol/l HbA1c 10% Osmolality (mosm/kg) 277 mosm/kg 285-295 mosm/kg 1] Consider each of these findings and give an assessment of the   patient’s glycaemic control. The above type 2 diabetic patient with abnormal biochemical values [high fasting plasma glucose, HbA1C, urea and borderline Osmolality] showing hyperglycaemic condition though the patient reported, that he had been tightly monitoring his glycaemic control. This describes either his nonadherance to medication [1-4] or fluctuations in plasma glucose levels as he is a newly diagnosed diabetic patient. So he requires more counselling [14] about the disease monitoring [8] and management [5-7], medication [medication regimen] alterations. The high fasting plasma glucose value 12 mmol/l shows patient is having high blood sugar levels at the time of testing and high HbA1C value [10%] gives a retrospective assessment of the mean plasma glucose concentration during the preceding 6-8 weeks. As the percentage is twice the normal value [ High urea value 10.1 mmol/l shows that renal impairment caused by diabetes mellitus. Plasma creatinine and urea levels are established markers of Glomerular filtration rate [GFR]. High urea value in above patient suggests that impaired function of the nephrons. It could be attributed to a fall in the filtering capacity of the kidney thus leading to accumulation of waste products within the system [12-14, 16]. Borderline osmolality 277 mosm/kg suggests possibility of disrupted water balance from either excessive water intake [polydipsia caused by hyperglycaemia] or inadequate water excretion [impaired kidney function]. In this case further investigations like measurement of urine osmolality, urine volume and urine, plasma electrolytes [sodium] to confirm the reason for hypo osmolality [9, 22]. Thus above all classical symptoms are suggestive of uncontrolled diabetes mellitus. 2] Discuss the importance of glycaemic control and the effects that poor control can cause in these patients. It is very essential to control the hyper glycaemia in diabetic patients as uncontrolled diabetes can cause life threatening consequences [14, 20]. Vascular disease is a common complication of persistent poor glycaemic control in diabetes [9, 13, 14-16]. Macro vascular disease due to abnormalities of large vessels may present as coronary artery, cerebrovascular or peripheral vascular insufficiency. A number of risk factors have been associated with the metabolic syndrome, including hypertension, poor glycaemic control, central obesity, smoking, dyslipidaemia and glycated end products [16]. Microvascular disease due to abnormalities of small blood vessels particularly affects the retina [diabetic retinopathy] and the kidney [nephropathy]; both may be related to inadequate glucose control. Microvascular disease of the kidney is associated with proteinuria and progressive renal failure. Diffuse nodular glomerulosclerosis [Kimmelstiel Wilson lesions] may cause the nephrotic syndrome. The renal complications may be partly due to the increased glycation of structural proteins in the arterial walls supplying the glomerular basement membrane; glycation of protein in the lens may cause cataracts. Skin disorders, Infections like urinary tract or chest infections, cellulitis, candida and erectile dysfunction is also most common and partly neurologically mediated. Diabetic neuropathy, which can be peripheral symmetric sensory, peripheral painful, acute mononueropathies or autonomic. Diabetic ulcers, which can be ischemic, infective. The joints can also be affected, Charcot’s joints [9]. Type 2 diabetic patients are more likely to suffer from a hyperosmolar hyperglycaemic non-ketotic state [HONK] when their diabetic control is deranged [17, 18]. Hypoglycaemia is most commonly caused by accidental over administration of insulin or oral anti diabetic drugs [9, 19]. 3] Describe how this particular patient could achieve a better glycaemic control. The above diabetic patient with abnormal biochemical values could achieve a better glycaemic control, by diet control, weight reduction [if patient is overweight], and increased physical activity, medication adherence, medication regimen alteration and most importantly high dose of insulin may be required to control the hyperglycaemic status [7, 9,17]. Additionally care providers must educate and motivate the patient to monitor glucose levels, control carbohydrate consumption and aggressively participate in self-care to control disorder. In type 2 diabetic patients incretin hormones [glucagon-like peptide-1 and glucose-dependant insulinotropic polypeptide] maintain normal glucose homeostasis. Thus dipeptidyl peptidase-4 inhibitors, which enhance endogenous incretin function, are well suited for combination with other agents to promote daily glycaemic control without increasing the risk of hypoglycaemia or weight gain [21]. In this patient insulin secretion can be stimulated by sulphonyl urea drugs. Metformin decreases intestinal glucose absorption and hepatic gluconeogenesis as well as increasing tissue insulin sensitivity and which is particularly used in obese patients [9]. Acarbose delays postprandial absorption of glucose by inhibiting alpha-glucosidase. Glitazones activate ÃŽ ³-peroxisome proliferator activated receptors and which can reduce insulin resistance. Repaglinide increases insulin release from pancreatic ÃŽ ²-cells [9]. Glycaemic control efforts should involve quarterly glycated haemoglobin assessments, routine monitoring of daily blood glucose values and combination therapy that targets both fasting and post prandial hyperglycaemia. The lifetime strategy for diabetes management might involve aggressive efforts to control glycaemia daily and early in type 2 diabetes, with less stringent glucose targets and avoidance of hypoglycaemia as possibility of comorbidities, such as advanced cardiovascular disease and renal impairment [8, 14, 16, and 20]. References 1] Khattab, M. et Al. [2010] Factors associated with poor glycemic control among patients with type 2 diabetes. Journal of Diabetes and its Complications, 24, 84-89. [Accessed 12th February 2015]. 2] Almutairi, A.M. et Al. [2013] Predictors of poor glycemic control among type 2 diabetic patients. American Journal of Medical Sciences, 3 (2), 17-21. [Accesses 12th February 2015]. 3] Blackburn, F D., Swidrovich, J., Lemstra, M. [2013] Nonadherence in type 2 diabetes, practical consideration for interpreting the literature. Patient Preference and Adherence, 7, 183-189. [Accessed 12th February 2015]. 4] Di Bonaventura, M. et Al. [2014] The association between nonadherence and glycated haemoglobin among type 2 diabetes patients using basal insulin analogs. Patient Preference and Adherence, 8, 873-882. [Accessed 11th February 2015]. 5] Moreira, Jr. D E. et Al. [2013] Glycemic control and diabetes management in hospitalized patients in Brazil. Diabetology and Metabolic Syndrome, 5, 62. Available from: http://www.dmsjournal.com/content/5/1/62 [Accessed 11th February 2015]. 6] Schmeltz, R.L. et Al. [2011] Management of inpatient hyperglycemia. Lab Med, 42 (2), 427-434. Available from: http://www.medscape.com/viewarticle/744866_4 [Accessed 13th February]. 7] Fowler, J. M. et Al. [2011] Pitfalls in outpatient diabetes management and inpatient glycemic control. Clinical. Diabetes Journal.Org, 29 (2), 79-85. Available from: http://clinical.diabetesjournals.org/content/29/2/79.full [Accessed 13th February 2015]. 8] Clarke, S. F. and Foster, J.R. [2012] A history of blood glucose meters and their role in self-monitoring of diabetes mellitus. British Journal of Biomedical Science, 69 (2), 83-93. [Accessed 13th February 2015]. 9] Crook, M.A. (2006) Clinical biochemistry. 7th ed. Hodder Arnold 10] Walker, S., Beckett, G., Rae, P. and Ashby, P. (2010) Lecture notes on clinical biochemistry. 8th ed. Wiley – Blackwell. 11] Marshall, WJ. and Bangert, SK. (2004) Clinical chemistry. 5th ed. Mosby 12] Idonije, O. B. et Al [2011] Plasma glucose, creatinine and urea levels in type 2 diabetic patients attending a Nigerian teaching hospital. Research Journal of Medical Sciences, 5 (1), 1-3. Available from: http://www.medwelljournals.com/fulltext/?doi=rjmsci.2011.1.3 [Accessed 13th February 2015]. 13] Alao, O. et Al. [2009] Cardiovascular risk factors among diabetic patients attending a Nigerian teaching hospital. The Internet Journal of Endocrinology, 6 (1), 1-8. Available from: https://ispub.com/IJEN/6/1/11009 [Accessed 13th February 2015]. 14] The management of type 2 diabetes [2014] NICE clinical guidelines 87. Available from: http://www.nice.org.uk/guidance/cg87 [Accessed 13th February 2015]. 15] Wallace, T. M and Matthews, D. R. [2000] Poor glycaemic control in type 2 diabetes: a conspiracy of disease, suboptimal therapy and attitude. The Quarterly Journal of Medicine, 93, 369-374. [Accessed 13th February 2015]. 16] Goud B. K, M. et Al. [2011] Serum urea, creatinine in relation to fasting plasma glucose levels in type 2 diabetic patients. International Journal of Pharmacy and Biological Sciences, 1 (3), 279-283. [Accessed 13th February 2015]. 17] Pesce, J. A. and Kaplan, A. L. [1987] Methods in Clinical Chemistry. Mosby. 18] Diabetic ketoacidosis. Information about DKA. Patient.co.uk. Available from: http://www.patient.co.uk/doctor/diabeticketoacidosis [Accessed 14th February 2015]. 19] Tight diabetic control. American Diabetes Association. Available from: http://www.diabetes.org/livingwithdiabetes/treatmentandcare/bloodglucosecontrol/tightdiabetescontrol.html [Accessed 14th February 2015]. 20] Ousman, MD. Y. and Sharma, MD. M. [2001] The irrefutable importance of glycemic control. Clinical Diabetes Journal.Org, 19 (2), 71-72. Available from: http://clinical.diabetesjournals.org/content/19/2/71.full [Accessed 14th February 2015]. 21] Bode, BW. [2009] Defining the importance of daily glycemic control and implications for type 2 diabetes management. Postgrad Med., 121 (5), 82-93. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19820277 [Accessed 14th February 2015]. 22] Weiner, D. Water regulation and osmolality. Available from: http://ocw.tufts.edu/data/33/497472.pdf [Accessed 17th February 2015]

Analysis of a High Toned Christian Woman

Samantha Kozera Ms. McGrath ENG 4U 20 March 2013 Analysis of A High-Toned Christian Woman The poem A High-Toned Christian Woman by Wallace Stevens used many sound devices to create an amazing poem and therefore should be considered to be â€Å"the best poem in the world†. If we dissect the poem, we can see that almost every line has a sound device that affects the poem’s atmosphere, meaning or use of words. The mood seemed playful from combinations of words and sound devices.The alliteration in line 19: â€Å"May, merely may, madame†¦Ã¢â‚¬  makes the speaker sound fun instead of strict. The onomatopoeia in line 18: â€Å"Such tink and tank and tunk-a-tunk-tunk†¦Ã¢â‚¬  also bring up the playful mood. His tone seems to be mocking the Christian woman’s beliefs instead of having a mature conversation. Repetition of â€Å"Madame† as well as â€Å"palm†, planets, and fiction makes it clear to the reader that these subjects are important. Ste vens creates comparisons from the first mention of those subjects to the next mention.For example, he states in the first line that â€Å"poetry is the supreme fiction† then later speaks about the woman’s beliefs as fiction as well. The author also repeats the subject planets. The first time the author speaks of planets is in a context of a â€Å"project beyond the planets† (Line 8-9). The project could be poetry and the place could be his imagination. Since we often associate something beyond the planets as Heaven (especially since Christianity is in our minds at this point), the author choses the repetition of planets to show that anything beyond it is a figment of the imagination.He speaks of Heaven in line 3 with an alliteration, â€Å"haunted Heaven† after he speaks about a â€Å"nave† (Line 2). This line creates a dark and cruel feeling. A nave is an empty place for worshippers and a haunted Heaven gives the idea that Heaven is a place for de ad worshippers. In line 2 and 3 assonance is used with the â€Å"a† sound being the emphasis. These lines are very important to the poem by putting emphasis on these lines the author brings that to the reader’s attention.The author’s diction and images like â€Å"Squiggling like saxophones† (Line 12), â€Å"muzzy bellies† (Line 16) and â€Å"jovial hullabaloo† (Line 20) make it seem like the speaker trying to persuade the woman to think a certain way and is making fun of what she thinks to accomplish that. The image of a widow wincing is a very sharp image that’s emphasised by the alliteration with the â€Å"w† sound that contrasts the fun mood. This could represent the comparison of the interpretation of poetry and the interpretation of religious literature.Also, this widow could represent the Christian woman, who is wincing at such crazy ideas spoken by the speaker of the poem. In conclusion, the sound devices and images cont ribute to the mood and meaning of the poem because it brings emphasis to important lines. Through connotations and alliterations, Wallace Stevens makes a short poem into a huge (controversial) idea. The fact that someone can accomplish this with only twenty-two lines makes it eligible to be the best poem ever.

How does Tim Butcher emphasise the problems and possible dangers faced on his journey during this passage?

There are many ways in which Tim Butcher emphasises danger during this passage; he does this through his language and through using other techniques such as using triplets. One example of danger is at the very start of the passage (bottom of page 59) and this is where we see the first use of a triplet – using this technique emphasises just how dangerous the Congo can be: â€Å"Thoughts of assassination, acid baths and dismembered bodies† This triplet is used to show the possible, brutal ways of facing death in the Congo – the fact that these are Butchers thoughts imply that he is worrying about facing his death in this way, the horror of it is something no one wants to experience. Butcher also uses an accumulative effect with this list of three as the next situation appears to be worse than the previous. Regardless of this, these three horrific examples are murders which are clearly planned and they show no respect for the dead. An assassination is usually an intentional act aimed at specific subject. As for the other two, acid baths and dismembered bodies seem to be two ways of hiding evidence and getting rid of a body. Neither of these three acts are accidents; all of them are intentional and done on purpose. Following on from this sentence, he mentions that the list of three were the only dark images on his mind. By saying that they weren’t the only images shows that there are many other situations he could be faced with, all of the same sort. The word ‘dark’ conveys the idea of how negative each of his thoughts are as it has connotations liked with is such as death and violence. Already from this first paragraph in the passage, we can see how much potential danger Tim Butcher could be faced with. Another way in which Tim Butcher presents danger is by using an anecdote of a friend who came close to death at the exact same airport he is at now – this makes the potential danger towards Butcher seem higher. The fact that his friend came close to death at the same place as him shows just how high the chance of him also facing death is. What really puts more emphasis on how dangerous the area is is when Butcher mentions his friend covers international crisis. This shows that he will have experienced many types of problems in his past – but none as bad as the Congo. Tim Butcher during this passage shows the majority of danger and problems through his choice of diction and emotive language. During the anecdote, he mentions that troops loyal to Mobuto were becoming increasingly desperate and were hoping to escape. Desperate’ shows how much troops wanted to escape from the power of Mobuto and the phrase ‘hoping to escape’ makes us think that the troops know escaping may be hard or even impossible, but they still try. The Congo is evidently a dangerous place especially for Journalists, as journalists are suspected to be Spies – Congolese people have no time to waste and judge this very quickly, we can tell this as Butcher tells us his friend was Seized. Being seized shows that an arrest was sudden and there was no hesitation in doing it. It comes across as forceful and out of the blue. After being seized, journalists are also stripped at Gunpoint – this shows a sense of danger as stripping someone to their underpants is immediate humiliation and shows vulnerability. Being held at gunpoint means that his friend was facing death, but to make this situation worse, the guards had him in this way for several terrifying hours. We can see here that the experience was being prolonged over seven hours; this makes the situation tenser for the victim as they could be shot at any minute – this is what makes it so terrifying. This section of the passage instantly tells us that the Congolese people are willing to kill. Shortly after this it is mentioned that it took hours of desperate pleading to convince the guards they were simply journalists. Desperate pleading shows how innocent the journalists are as they know having tapes gave the Congolese people the wrong impression. By the use of the word convincing, it implies that the guards weren’t taking their word for it and genuinely believed they were spies. Tim Butcher has again used the idea of the situation being prolonged over a long period of time to emphasise how serious it was. By mentioning they were ‘simply journalists’ it shows how strict the guards are in the Congo; it must have been obvious that the visitors were just journalists and the Congolese people should know they get visitors but they take things too far. During this passage, there is another example of vulnerability being shown; this occurs when an Asian lady lands into the airport and has her luggage taken off her and she has to auction for it to given back to her.

Multiplayer Online Role Playing Games Eve Essays - 975 Words

Eve online is a massive multiplayer online role-playing game developed by CCP games and released in May 2003. Since then, CCP have released new content and major expansions every six months, creating one of the largest and most detailed games ever. Eve is known as a hard game to get a start in. Advancing your character happens in real-time, even if youre not logged in, and getting good at a specific job can take a couple of days or a few months. To get anywhere in Eve you need to work together with other players. Players can fly solo, but grouping up can make generating ISK, the main currency in Eve, much easier. Like minded players can form groups known as Corps, which work like a guilds or clans in other MMOs. Being in a larger Corp†¦show more content†¦They are the goal for most miners as a single cargo hold can give you enough ISK to upgrade your mining ship and buy a few more ships for PvP. Mining ships are easy to skill into and dedicated miners are always sought by Corps that manufacture or work in riskier systems. 2. Mission running If mining doesnt interest you, there are non player characters(NPCs) in every system that will give you missions in return for ISK and items. Missions rank from level 1, which you can do with one player, to level 5 which need at least two skilled pilots in high level ships. Missions are more combat oriented, although there are some that only need you to move items from one system to another. Grouping up with some friends or corp mates can help you run through missions faster and generate more income than running solo. Running missions will help you learn about the combat side of Eve, such as what sort of defences or weapons are most effective as well as the strengths and weaknesses of your ships. 3. Trader Trading is the most lucrative activity you can do in Eve, but it does need a lot of reasearch to be succesful. Knowing which items are useful and where they are in short supply can boost your income considerably. Most traders start by mining enough asteroids to afford an industrial ship which have a large cargo space and good defences, then head to aShow MoreRelatedThe Problem Of Online Gaming1677 Words   |  7 Pagescontinue their gaming experience all the way in to adulthood as a hobby. Online gaming is a relatively new experience, having really been brought into light in the past decade with the introduction of broadband internet. (Cash 2012) A study done by researchers at Iowa State University and the National Institute on Media and the Family stated that a nationwide survey of 1,178 American youth aged 8 to 18, found 1 in 10 video game players or 8.5 percent of American youth, show some signs of being addictedRead MoreThe Multiplier Online Games ( Mog )1546 Words   |  7 P agesIntroduction: Multiplier Online Games (MOG) are one kind of real-time applications. These are developed using either centralized architecture (Client-Server Architecture) also known as traditional architecture or using distributed architecture (Peer to Peer Architecture). Some games are developed using a combination of these two architectures known as Mirrored Server Architecture (Hsu, Ling, Li, Kuo, 2003). In general, games are two types. One is role based playing games where players role is fixed. OtherRead MoreInternet Addiction: an Escape from Reality3096 Words   |  13 PagesInternet Addiction: An Escape from Reality With the creation of an online world comes the creation of new problems. The great network system known as the Internet has allowed for huge advances in the world, while creating very serious issues as well. Perhaps one of the most common of these negative issues is Internet Addiction Disorder, or IAD. Doctors Aviv Weinstein and Michel Lejoyeux define Internet addiction as being â€Å"characterized by excessive or poorly controlled preoccupations, urgesRead MoreSci Damath Andoroid Game9675 Words   |  39 Pagesdevice is the mobile phone. Android phones are very popular now a day. Every month there are new releases of the newest model and brand. Mobile phones are using android operating system. Android phones are effective for the new generation of virtual game and other application. People used their mobile phone by connecting and communicating to others, but android phones can also be use as an entertainment in different application. Android phones are very popular now a day. Every month there are new