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Heavy met- al toxicity has been associated with feeding crushed shell derived from contaminated sources (oysters raised in polluted waters) generic 60 ml liv 52 with amex medications zyprexa. The bird was maintained indoors and povitaminosis A leads to squamous metaplasia of had no exposure to sunlight or water for bathing liv 52 100 ml with amex medicine man gallery. Horny beak material that is dry and flaky buy 60 ml liv 52 overnight delivery treatment 7th march, as well as black discoloration of the epithelial surfaces causing obstruction of respiratory feathers are typical of malnutrition purchase 200 ml liv 52 mastercard medicine and technology. Dyspnea may be change in diet and daily exposure to direct (unfiltered through caused by calcium or vitamin D deficiency if severe3 glass) sunlight. This can occur if a ciency causes the formation of ragged feathers, while tube is accidentally placed in the trachea when at- a deficiency in growing cockatiels has been associ- tempting crop feeding or if a bird (particularly a weak 46 ated with a lack of contour feathers. The association between diet and feather pigment Plumage Abnormalities has long been recognized by canary breeders. Caro- tene and xanthophyll pigments, which originate from Dark, horizontal lines (stress marks) on feathers plant material, are found in fat globules in the feath- have been associated with nutritional deficiencies ers and give rise to yellow, orange and red colors (see (particularly methionine) and indicate that a release Chapter 24). Birds lacking a dietary source of carote- of corticosteroid hormone occurred while the feather noids may develop muted feather or skin colors, was developing. Stress lines are common in neonates while dietary supplementation of carotenoids in that have had a disrupted feeding schedule or in birds with suitable genetic backgrounds will result in raptors that are molting while in a training period increased depth of color. Molting abnormalities, retained feather sheaths and dry flaking beaks have also been Prolonged feeding of bacon rind and bone marrow associated with overall nutritional deficiencies (Fig- has been associated with an oily feather and stool ure 31. Raptors Feather picking may be initiated by dry, flaky, fed laboratory rats and mice (reduced carotenes) may pruritic skin, which in turn can be caused by nutri- lose the yellow coloration of their cere, feet and legs tional deficiencies, particularly deficiencies of vita- that is characteristic in free-ranging birds. Porphyrins are less sensitive to dietary influ- possible cause of self mutilation (Figure 31. The black feathers in this Amazon parrot resolved with a change in diet Melanin occurs in granules in the skin and feathers (seeds to formulated diet) and correction of chronic active hepatitis. This pigment is derived from tyrosine in an enzy- occurs, melanin granules in the middle of the feather, matic reaction requiring copper. Consequently, defi- if present, would absorb all wave lengths of light, ciencies of tyrosine (or other related amino acids) or giving the visual effect of black (Figure 31. In deficiency, timing of the deficiency in relation to most cases, their occurrence depends on a scattering feather development and the initial color of the af- of light caused by the structure of the keratin in the fected feathers. While lysine deficiency in chickens, spongy layer of the feather rami rather than on the turkeys and quail produces achromatosis, there was presence of pigments. Essential amino acids that no loss of feather color in young cockatiels fed a occur in keratin include methionine, histidine, ly- lysine-deficient diet. However, choline and riboflavin sine, tryptophan, threonine, isoleucine and valine. It deficiencies produced feather changes in young is possible that amino acid deficiencies could alter the cockatiels that resembled achromatosis caused by structure of keratin and consequently alter feather lysine deficiency in poultry. A change in feather color from green to yellow associated with breakage) in feathers may be associ- is usually caused by a loss of structural blue color, ated with a hypovitaminosis B (Figure 31. While this color change is commonly Skin Changes seen in nutritionally deficient Psittaciformes, the exact nature of the deficiency has not been clarified, Plantar corns and pododermatitis have been associ- and it is possible that more than one amino acid could ated with biotin and vitamin A deficiencies, particu- be involved (see Color 24). If a formulated diet is not available, a diet can to black or grey to black in birds that are sick or be supplemented with multivitamins to compensate malnourished. Several kiwis in a with altered keratin structure in the spongy layer New Zealand zoo developed a scaly dermatitis over that prevents normal light scattering. The bird was on an all-seed diet frequently brittle and may break at the site of abnormal coloration. Changing the diet, increasing the exercise (out- door flight enclosure) and standard treatment for grade 4 bumble- ment that was routinely included in their diet was foot were effective in resolving the lesions. The clinical problem resolved when the mul- tivitamin supplement was again added to the diet. Over-supplementation may cause problems with excess vitamin, mineral, fat or protein Tibial dyschondroplasia is characterized by uncalci- consumption. A genetic predisposition along with electro- Demineralized, bent bones and pathologic fractures lyte imbalances involving sodium, potassium and may occur in birds with hypovitaminosis D and cal- chloride are thought to be involved in the develop- cium, phosphorus or magnesium deficiencies or im- ment of tibial dyschondroplasia. Leg paralysis has been associated with calcium, chloride or riboflavin deficiency. Slipped tendon of the hock (perosis) may occur with manganese, biotin, pantothenic acid or folic acid de- Cervical paralysis has been associated with a folic ficiencies (see Color 8). Jerky leg movements have been asso- allowed sufficient exercise and birds fed high-min- ciated with pyridoxine deficiency. There is gross enlargement of the tibiometatarsal joint, twist- Sudden collapse or fainting has been associated with ing and bending of the distal tibia and slipping of the hypoglycemia in raptors or in other species when a gastrocnemius muscle from its condyles. Syncope is naceous birds, cranes and ratites are particularly characteristic of advanced hypocalcemia in African susceptible to this condition. In some cases, surgical correction is possible (see Behavioral changes including aggressiveness (bit- Chapter 46). In spite of the absence of complete data for companion birds, anecdotal findings and scientifically supported in- Reproductive Disorders vestigations suggest that general health and repro- Many dietary deficiencies or excesses may result in ductive success will be greater in birds fed “balanced” reduced reproductive performance due to infertility, formulated diets supplemented with limited fresh poor hatchability or nestling deaths. Calcium, vita- fruits and vegetables compared to birds fed seeds min E and selenium deficiencies may be associated supplemented with fresh fruits and vegetables (Fig- ure 31. Research findings and clinical experience suggest General Ill Health or Sudden Death that there is considerable interspecies variation in nutrient requirements and in clinical signs of malnu- Fatty liver infiltration may occur due to high fat trition. For example, some finches may consume up diets, fatty acid or B vitamin deficiencies and high- to 30% of their body weight, budgerigars, 25% of body energy diets in exercise-deprived birds (see Color 20). Ascites may be as- of extrapolating nutrient requirements, particularly sociated with excessive dietary levels of iron in birds of minerals, from poultry data when the level of food susceptible to iron storage disease (hemochroma- consumption varies dramatically. Atherosclerosis may be associated with diets also vary depending on the bird’s age and physiologic high in fat and cholesterol (see Color 14). Aortic rupture has been associated with copper defi- ciency in poultry and is suspected to occur in ratites (see Color 48). Protein and Amino Acids Protein in the diet is broken down into component Immune Response amino acids before being absorbed by the intestine. Adequate levels of both B complex (particularly pan- tothenic acid and riboflavin) and vitamin E have been shown to improve the body’s response to pathogens. In poultry, vitamin C and zinc are involved in T-cell re- sponse, and vitamin C stimulates macrophages and helps to counter the immunosuppressant effects of stress. Low vitamin A levels may result in a sub-opti- mal immune response and have been associated with the occurrence of aspergillosis in psittacines. Over- supplementation with fresh foods, as is the case with this daily vegetable bowl for a cockatoo, can actually cause malnutrition When one considers the array of ecological niches to through insufficient consumption of a formulated diet. For a bird the size of an Umbrella Cockatoo, the formulated diet should be which different species of birds are adapted, it is not supplemented with the equivalent of several slices of carrot (or surprising that there are major species differences in dark squash or sweet potato), one-eighth cup of spinach (or broccoli or endive) and several small slices of favorite fruits as a treat. Excess Dietary Protein Dietary protein requirements vary dramatically be- Diets for Birds with Renal Disease or Gout tween species. Broiler chickens and turkeys have Birds with renal disease or gout should be provided been genetically selected for rapid growth and are fed diets that decrease the workload of the kidneys and high protein levels to achieve maximum growth slow the loss of renal function. These feeding practices are rarely appropriate lower in protein and meet energy needs with non- in other species. Calcium, phosphorus, magnesium, pheasants may contain nearly 30% protein, but sodium and vitamin D3 levels should be reduced to young ratites, waterfowl and psittacine birds require avoid renal mineralization.


  • Signs of dehydration
  • Has the memory loss been getting worse over years?
  • Dullness of the eardrum when a light is used
  • Washing of the skin (irrigation) -- perhaps every few hours for several days
  • Rapid heart rate
  • Is the thirst decreased or totally absent?
  • Encephalopathy
  • Vomiting

Occasionally buy cheap liv 52 100 ml line symptoms nicotine withdrawal, people may volunteer a false confession to assist or protect the real culprit discount 100 ml liv 52 mastercard medications for ocd. Gudjonsson (52) highlights some evidence that confessing to crimes to protect others may be particularly common in juvenile delinquents liv 52 120 ml low price medications zofran. Finally generic 200 ml liv 52 with amex medicine vile, Shepherd (53) identifies a subset of individuals who falsely con- fess to crimes to preempt further investigation of a more serious crime. Accommodating-Compliant False Confessions Expanding on the original three distinct categories of false confession, Shepherd recognizes a group of people for whom acquiescing with the police is more important than contradicting police assertions about what happened. In such circumstances, a false confession arises from a strong need for approval and to be liked. Police conduct is noncoercive, although it does involve the use of leading questions sufficiently obvious to suggest to the suspect what answers the police want to hear. People at all intellectual levels are at risk of behaving in this manner, with those who are excessively compliant being at greatest risk. Coerced-Compliant False Confessions Coerced-compliant false confessions are typically elicited during persua- sive interrogation: the person perceives that there is some immediate instrumen- tal gain from confessing. The suspect does not confess voluntarily but comes to give into the demands and pressures of the interrogators. He or she is fully aware of not having committed the crime of which he or she is accused, and the con- fession is usually retracted once the immediate threat is gone. Care of Detainees 219 Gudjonsson (52) suggests that the four main types of perceived immediate gain are: being allowed home after confessing, bringing the interview to an end, a means of coping with the demand characteristics (including the perceived pressure) of the situation, and avoidance of being detained in police custody. In these circumstances, the suspect may be vaguely or fully aware of the consequences of making a false self-incriminating statement, but the perceived immediate gain outweighs, in his or her mind, the potential long-term conse- quences. These suspects may naïvely believe that the truth will come out later in court, perpetuating the belief shared by many police officers and legal advisers that what happens in the police station is not really that important. Coerced-Internalized False Confessions Coerced-internalized false confessions occur when suspects are gradu- ally persuaded that they have committed a crime of which they have no recol- lection or when they have become so confused that they begin to mistrust their own memory and accept a false scenario suggested by the police. This type of confession can happen under the following two distinct conditions: 1. The suspects have no memory of the alleged offense, even whether or not they committed it. In essence, the suspects have no clear recollection of what they were doing at the time the offense was committed and believe they must have committed the crime. At the outset of the interview, the suspects have a clear recollection that they were not involved in the alleged offense. However, as a result of subtle manipu- lative techniques employed by the interrogator, they begin to distrust their own memory and beliefs. Interrogators attempt to undermine the suspects’ confidence in their own recollection of events, which would create sufficient self-doubt and confusion to cause them to adjust their perceptions of reality. In contrast to the makers of coerced-compliant false confessions, those who make coerced-internalized false confessions only retract their confessions when they realize, or suspect, that they are in fact innocent. These retractions can take considerable time and, occasionally, may never occur if the original memory of events becomes permanently distorted. Suggestibility and Compliance Vitally important to an understanding of why false confessions can often prove so incriminating is an awareness of the theory of interrogative suggest- ibility (54,55). At the heart of the theory is the way leading questions can produce distorted responses from suspects because they are phrased to sug- gest the expected response. Through this process people can come to accept a piece of postevent information and incorporate it into their memory, thus 220 Norfolk and Stark appearing to have “special knowledge” about the alleged offense. This spe- cial knowledge may seriously mislead the police and the courts to assume the suspect’s guilt erroneously. Suggestibility correlates with anxiety, lack of assertiveness, poor self-esteem, and low intelligence (56). Compliance refers to the tendency of people to obey the instructions of others when they don’t really want to, because they are either overeager to please or simply unable to resist the pressure (57). The traits of both suggest- ibility and compliance are relevant to the issue of false confessions (58). Preventing False Confessions It is a fundamental tenet of both American and English law that reliance should only be placed on confession evidence that is given freely and voluntar- ily. In considering the voluntary nature of a confession, several factors need to be considered. These include the vulnerability of the accused (through factors such as age, mental illness and handicap, physical illness or injury, and intoxi- cation), the conditions of detention (lack of access to legal advice, failure to be given legal rights, and adequate rest periods during detention), and the charac- teristics of the interrogation (threats, physical abuse, and inducements). In America, the most important legal development designed to protect the rights of suspects and deter police misconduct relates to the case of Miranda v. The effect of this judgment was to ensure that all criminal suspects in police custody must be warned against self- incrimination and made aware of their right to remain silent and to receive legal advice. These rights have to be actively waived by the accused before interroga- tion can commence, and any violations of the requirements render any subse- quent confession inadmissible. In the United Kingdom, statutory safeguards are provided by the Police and Criminal Evidence Act 1984 and the Codes of Practice set up under sec- tion 66 of this Act (1), which regulate practice in respect to several matters, including the detention, treatment, and questioning of persons by police offic- ers. Confessions will generally be inadmissible if the provisions of the Codes of Practice are breached by the police (60,61). The role of the forensic physician when assessing a suspect’s fitness for interview is seen as fitting into this overall legal framework, the doctor’s primary concern being to recognize any characteristics that might render the individual vulnerable to providing a false confession so that adequate safe- guards can be put in place. To address this deficiency, Norfolk (63) proposed a definition that was used as the starting point for discussion by a subgroup set up by the Home Office Working Party on Police Surgeons in the United Kingdom. That working party made an in- terim recommendation (64) that has now been modified and included in the 2003 revision of the Police and Criminal Evidence Act Codes of Practice (1), thus providing the first Parliamentary approved definition of the term fitness for interview. The Codes of Practice state that: A detainee may be at risk in an interview if it is considered that: (a) Conducting the interview could significantly harm the detainee’s physi- cal or mental state (b) Anything the detainee says in the interview about their involvement or suspected involvement in the offense about which they are being inter- viewed might be considered unreliable in subsequent court proceed- ings because of their physical or mental state. Thus, a suspect with known ischemic heart disease who is experiencing chest pain satisfies the criteria of (a) above and clearly needs assessment and appropriate treatment before it is safe to conduct an interrogation. The concept of unreliability may be harder to evaluate and will require consideration of the various vulnerability factors associated with false confes- sions. In making an assessment, the Codes of Practice require the doctor to consider the following: 1. How the detainee’s physical or mental state might affect their ability to under- stand the nature and purpose of the interview, to comprehend what is being asked, and to appreciate the significance of any answers given and make rational deci- sions about whether they want to say anything. The extent to which the detainee’s replies may be affected by their physical or mental condition rather than representing a rational and accurate explanation of their involvement in the offense. How the nature of the interview, which could include particularly probing ques- tions, might affect the detainee. Scheme of Examination When assessing a detainee’s fitness for interview, the traditional medi- cal model of taking a history and then conducting an examination should be 222 Norfolk and Stark employed. As always, informed consent should be obtained and detailed and contemporaneous notes should be taken. The History As much background information as is practicable should be obtained and, when possible, an indication of how long any interview is likely to take. The demand characteristics of a long interview about a suspected murder will be much greater than a short interview about a shoplifting offense.

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Injectable doxycycline should be used within six hours of being Low therapeutic index buy cheap liv 52 60 ml on line treatment urinary incontinence. If dimetridazole is added to the food or drinking water buy liv 52 200 ml low price medicine vile, maintained in the freezer cheap 60 ml liv 52 with visa symptoms 2dp5dt. In general cheap 120 ml liv 52 fast delivery symptoms hiv, the time-related degenera- a toxic level may be consumed or fed to a mate or nestlings. Extended therapy or excessive dosing may result vomiting continues, the dose should be reduced in 5 mg/kg inter- in toxicity. Some affected birds may respond to treatment with B vita- tive to doxycycline and are the most frequent species to regurgitate mins. Contains proliferation of candida when any tetracycline is being adminis- naturally occurring prostaglandin F2 alpha. Doxycycline does persist and may stop oviposition in egg- be effective in some cases of egg retention. Toucans, particularly young birds, are sensitive to expected to relax the vagina and increase uterine tone, which may tetracyclines and may develop bone deformities following its use facilitate the passage of an egg. Used as a chelating Available as a capsule (25 or 50 mg) for oral administration or agent. Low May be effective in calming some feather pickers or excessively therapeutic index. May Available as a solution (a derivative of Angustifolia purpurea) for be helpful in reversing the respiratory depressant effects of oral administration. Materials to prepare the solution are may be helpful in some cases of feather picking. Toxic if administered Available as a suspension (5 mg/ml, Vibramycin monohydrate), orally or parenterally. Particularly effective in treating pseudo- syrup (10 mg/ml, Vibramycin calcium syrup) or capsules (100 mg, monas dermatitis and sinusitis. Should not be used to stop bleeding associated with as an injectable solution (22. Placing a foreign compound Baytril is the veterinary-labelled form of a fluroquinolone class of into a feather follicle can cause the formation of feather cysts. There is no advantage to using Available as tablets (50, 100 or 200 mg) for oral administration or ciprofloxacin in place of enrofloxacin. Many gram-negative bacteria, par- activity for aspergillosis, candida and cryptococcus. Passes blood- ticularly pseudomonas, are resistant to enrofloxacin and ciproflox- brain barrier. Early studies show encouraging results in chlamydia May not be compatible with other antifungals. Birds should be monitored for the devel- tation may occur in some species, particularly cockatoos and opment of secondary yeast infections. Hens receiving 800 Available as a capsule (250 and 500 mg) for oral administration. Because nystatin is not absorbed from the gut, flucytos- zole for ten days was found to have renal damage. This drug should ine may be used to treat candida infections in other organ systems be used with caution in young birds. Clinical indications are confined to desperate hibitor that functions as a non-steroidal analgesic, anti-inflamma- attempts at restoring cardiac function in cases of peracute death tory and antipyretic agent. Used in conjunction Has been associated with congestive heart failure and death in with calcium gluconate to induce the passage of an egg from the chicks, ducklings and turkey poults. Contraindicated if the egg is adhered to the wall of the oviduct or if a mechanical blockage is preventing egg passage. Furosemide should be considered to have administration or as tablets (250 or 500 mg) or solutions for oral a low therapeutic index in birds. Available as an injectable solution (50 mg/ml) that may be used orally, intranasally, topically or for nebulization. For nebulization, 1 ml of injectable solu- for the treatment of Mycobacterium spp. A transient Fenbendazole should not be used while active feather development polyuria indicative of renal damage is common. Will oxidize if exposed to light and must be stored in death in some avian species, particularly lories. Concentrated solution is made by mixing two ministration of amikacin is safer in birds. Working solution is mixed solution must be used with caution in small birds to prevent fresh daily by mixing one drop of concentrated solution in 250 ml overdosing and nephrotoxicity. The toxic effects of aminogly- in toucans and mynah birds that are prone to hemochromatosis. Can be used to treat gastrointestinal candidiasis cause a fatal hepatitis, vomiting, depression and ataxia. May be effective in Has been associated with anorexia and depression in African Grey some cases of feather picking and self-mutilation in birds. African Grey Parrots and Quaker Para- effective against aspergillosis in Psittaciformes with few side ef- keets may be disoriented or neurotic following administration. Most Administration should be discontinued if anorexia, ataxia or vom- effective therapy for Knemidokoptes. Quaker Parakeets and Umbrella and Moluccan Cocka- topically on affected areas or can be given orally. May also be effective for Oxyspirura, some coccidia, some nema- todes, gapeworms and sternostamatosis. Toxic in bullfinches and goldfinches when used Often combined with piperazine for the treatment of capillaria in topically at 0. Low therapeutic index in Psittaciformes, Anseriformes solution designed for cattle and pig use. Ivermectin diluted in propylene glycol will Found as a fiber source in some formulated diets. May be effective settle out and the diluted product should be thoroughly mixed in controlling glucosuria, hypocalcemia and hypercholesterolemia. The water-soluble preparation designed for Can be administered as a bulk laxative to aid in the passage of use in horses is easier to work with and appears to be safer. Large doses may precipitate out in the crop or However, deaths in finches and budgerigars have been reported upper intestinal tract causing an impaction. The drug or its metabolites should not be allowed to responsive to traditional therapy.

Clearly the lifestyle intervention was significantly more effective than metformin—a drug with sometimes serious side effects buy liv 52 100 ml with mastercard symptoms inner ear infection. Reducing chemical exposure by choosing organic food when possible discount 100 ml liv 52 otc medications ending in pril, by using natural cleaners at home generic 120 ml liv 52 with visa z pak medications, and by not using chemical pesticides is a valid step to help prevent environmental toxins from negatively affecting insulin regulation in the body purchase liv 52 60 ml on-line medicine 832. Clinical Monitoring Knowledge and awareness are the greatest allies for people with diabetes. An individual with diabetes who makes a strong commitment to learning about his or her condition and who accepts the lead role in a carefully supervised monitoring program greatly improves the likelihood of living a long and healthy life. On the other hand, individuals who remain blissfully ignorant about their disease and who refuse to undergo regular testing or self-monitoring are far more likely to face years of unnecessary suffering and, more often than not, catastrophic health problems. Diabetes can be viewed as a state of biochemical and hormonal anarchy that, unless properly managed and supervised, will lead to organ injury and accelerated aging. Many of the complex control systems that faithfully govern and protect the body are damaged in the diabetic. In order to regain control, a diabetic must learn how to maintain intimate awareness of blood sugar levels, risk factors for atherosclerosis (hardening of the arteries), blood pressure, body mass index, level of fitness, and other factors that determine the risk of developing diabetic complications and eroding quality of life. Fortunately, diabetics who do pay attention to these risk factors through regular testing and a properly supervised self-monitoring program are also those who are much more likely to benefit from changes in lifestyle and diet, supplements, and, when necessary, medications. Self-Monitoring of Blood Glucose Levels Since its introduction, self-monitoring of blood glucose has revolutionized the management of diabetes. Diabetics who do not remain aware of their blood glucose and who do not make every effort to keep their blood sugar under tight control can expect a significant increase in their risk of serious health problems such as eye, kidney, and heart disease, as well as a number of other problems such as depression, fatigue, impotence, and chronic infections. Self-monitoring of blood glucose is important for various reasons:79 • Modifications of treatment to achieve appropriate blood glucose control • Detection and diagnosis of hypoglycemia • The ability to adjust care in response to shifts in daily life circumstances (e. In the absence of diabetes, the pancreas monitors blood glucose continuously and adjusts its insulin output moment by moment in response to changes in blood glucose. In order to achieve blood glucose levels that are consistently as close to normal as possible, type 1 diabetics must replicate this natural function as closely as possible. This means that they need to monitor their blood glucose frequently, and they must learn to use this information to make ongoing adjustments to their insulin injections, diet, and exercise. Intensive insulin therapy allows a diabetic to achieve near-normal levels of blood glucose while enjoying improved lifestyle flexibility. With conventional, infrequent insulin injections, the diabetic must structure meals and other aspects of lifestyle around these injections or face serious abnormalities of blood glucose. On the other hand, with intensive insulin therapy that relies on rapid- acting, short-duration insulin or the use of an insulin pump (an electronic device that provides a continuous injection of short-acting insulin with extra boosts before meals), the timing and size of doses can be adjusted to suit the events of the day. Type 2 Diabetes and Self-Monitoring of Blood Glucose Levels Self-monitoring of blood glucose has an important place in the management of type 2 diabetes as well. Each type 2 diabetic lies somewhere on a spectrum, with one end of the spectrum being mild glucose intolerance (accompanied by insulin resistance and higher-than-normal levels of insulin) and the other end of the spectrum being more advanced forms (with more severe insulin resistance, the potential for high blood glucose and ketoacidosis, and partial or nearly complete pancreatic failure with an accompanying lack of insulin). Self-monitoring of blood glucose plays a varying role depending on the severity of the disease. Every type 2 diabetic should own a blood glucose monitor and become familiar with its use. Even those diabetics whose blood glucose is well controlled through diet, lifestyle, and supplements should measure their blood glucose regularly. Numerous dietary factors, supplements, exercise, stress, and illness can all have a significant impact on blood glucose control. Becoming aware of how all these factors influence diabetes will help motivate type 2 diabetics to make positive changes, and monitoring will provide immediate feedback about the results of any changes. Diabetics who have a more serious case of disease, with diminished pancreatic insulin production, may benefit from efforts to establish consistently near-normal blood glucose control using intensive insulin therapy similar to that of type 1 diabetics. If diabetics are placed on an intensive insulin therapy program, they must self-monitor their blood glucose as frequently as type 1 diabetics on intensive insulin therapy (usually before and two hours after each meal). One way to achieve optimal blood glucose in these individuals is to give a daily injection of long- acting insulin (Lantus), which provides a smooth, continual release of insulin for 24 hours, in addition to diet and medication. Diabetics on this type of program definitely need to measure blood glucose frequently. Guidelines for Self-Monitored Blood Glucose • Test on awakening and just before each meal. C-Peptide Determination Often it is important to know if the pancreas of a diabetic is making insulin, and if so, how much. This assessment can greatly influence treatment, especially in a diabetic hoping to avoid or cease using insulin. The level of pancreatic insulin production can also partially determine the types of medication or natural health products that are more likely to be effective. Once it is known how well the pancreas is producing insulin, the focus may be shifted toward replacing deficiencies in insulin production, stimulating insulin production, preserving pancreatic function, reducing insulin resistance, or a combination of these therapeutic efforts. A piece of this protein (C-peptide) is then snipped off by enzymes, and both C-peptide and the remaining insulin are released into the bloodstream. Measuring C-peptide can be helpful in both type 1 and type 2, but generally is more so for type 2. In type 1, measuring C-peptide can uncover how much insulin the pancreas is making, which may help indicate how much of the pancreas is still active. In type 2, high C-peptide levels confirm that the patient is very insulin resistant. Low C- peptide levels may indicate that enough damage has occurred to the pancreas that the patient needs to be put on some manner of insulin therapy. Post–surgical removal of pancreas; rare Urine Ketone Testing In any circumstance when the body must derive its primary source of energy from fat, ketones are produced as a by-product. In general this is associated only with type 1 diabetic patients, as the vast majority of type 2 patients do not develop ketoacidosis. Ketoacidosis can occur if an insulin-dependent diabetic forgets to take insulin or deliberately avoids taking it. It can also occur when a diabetic becomes ill or injured or is given high doses of cortisone-type drugs. All of these phenomena may result in a severe loss of insulin effectiveness, with the cells unable to take up and use glucose. In such circumstances, blood glucose rises to extraordinarily high levels, large amounts of fat are used by cells that cannot take in glucose, and the blood becomes polluted with toxic levels of acidic ketones. Severe dehydration occurs rapidly because the kidneys are unable to conserve water in the presence of such high levels of blood glucose. Because of this, testing the urine for ketones (or, even better, testing the blood for ketones, by use of a special glucometer that has this extra testing capability) remains an important part of monitoring for type 1 patients with no pancreatic function left at all. The presence of urine or blood ketones, accompanied by high blood sugar readings, can help determine how far along the ketoacidosis has developed and what type of medical attention is required. For this reason, all type 1 diabetics should frequently test their urine for ketones during acute illness or severe stress, especially when blood glucose levels are consistently elevated (>300 mg/dl [16. Monitoring by a Physician Although diabetics must take charge of their condition, controlling diet, managing lifestyle, and monitoring blood glucose, they are rarely successful without professional guidance.

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