Case Study: Neglect

This case involves a 16 year old male and subsequently four of his younger siblings. In elementary school, the client earned â€Å"A† and â€Å"B† grades. However, this did not continue in high school. Additionally, the once active boy began to isolate. He stopped playing basketball and spent more time in the counselor’s office just to avoid the other children as they often made fun of him. The client began seeing the school counselor when he was ten years old. His parents were both alcoholics and were involved in using and selling illegal substances. The living conditions at home were unbearable. There was often no food, electricity, or water in the home. The client reported that the windows were only screen, leaving the home freezing. The client also reported that his parents would lock him and his siblings in their room to ensure they did not tell authorities the truth about what was going on in the house. This typically occurred when the parents got word that the police or the Department of Family Services was on their way over. There was five children in this family, the client was the oldest, four child were currently still in the home. In addition to the neglect the client experienced, he also experienced abuse. This case study mentioned one obvious incident. When the client returned to his parent’s home after staying with his aunt’s because of neglect charge, he came back to school with a broken arm. This was the only indication of physical abuse during this case study, however the client did not discuss what happened. Additional physical abuse or any other type of abuse is unknown. This client was also responsible for his siblings. He made sure they were dressed and feed for school. He also assisted his siblings with their homework. This responsibility left no time for him resulting in poor grades and his social life decreased. The client also displayed symptoms of hopelessness, suggesting depression. The school counselor made note of possible diagnoses, however, it does not appear that the counselor ever made an official diagnosis. The counselor did mention Depression as a primary diagnosis due to the client’s negative doom related vocabulary. Treating this client for depression may be helpful. To meet a diagnosis of Depression the individual must experience at least five of the following symptoms in the same two weeks: depressed mood, weight loss or gain, too much or too little sleep, increased or decreased psychomotor activity, fatigue, feelings of worthlessness, poor concentration, or suicidal ideation. These symptoms must be significant enough to cause marked impairment in work or school. This client did display many of these symptoms. For example, the therapist stated that the client said the word â€Å"hopeless† often. The client also looked underweight, had difficulty in school both academically and socially, and did not receive the proper amount of sleep (DSM-IV-TR). Finally, these symptoms must be more severe than the common blues everyone experiences from time to time. While this client was probably suffering with some degree of depression, there were other factors which better explain these symptoms. This client was the victim of child neglect and abuse. As noted above the children in this family often went without their basic needs. This is a better explanation for the client’s symptoms than depression because when placed in a more nurturing environment, the client’s symptoms dissipated. The client displayed this change in behavior when the courts sent the children to the aunt’s home after the client called the Department of Family Services to file the neglect report. During this time, all the children were going to school clean and feed. The children’s homework, including the client’s was completed. This dissipation of symptoms was seen a second time when the client was placed in foster care. Again, he was going to school clean and feed and with homework completed. Once at his foster parent’s home, the client was also able to go back to playing basketball again. During the course of the client and school counselor relationship, the client saw the counselor on a weekly basis. The school counselor designed these meetings to assist the client in problem solving with regard to caring for his younger siblings. The counselor’s recognition of the client’s needs in this regard was definitely a factor in the client’s ability to make it through this difficult time. This is not always the case in turn causing the client to feel that therapy does not work. Additionally, the counselor did not push the client for information or action so a healthy relationship was able to develop. The counselor was able to slowly earn the client’s trust by showing him she was there for him. This benefited the client in a number of ways. He was able to develop a positive supportive relationship with an adult role model and he was able to gain the courage and strength to put an end to the neglect he was experiencing. As the client progressed in his problem solving and decision making skills the therapist should modify the methods and goals of the therapy sessions. Once the client moved from his biological parents and later adopted, his roles and responsibilities changed drastically. With the new family he lived as a normal child, he was clean, well feed, and rejoined the school’s basketball team. He no longer had to care for younger children in a parenting capacity. At this point therapy should move the focus to resolving the issues of abuse and neglect so the client can come to terms with his past. The use of psychoanalytic therapy would be an appropriate therapeutic method. With this type of therapy the client is able to talk out his issues. With the help of the therapist, the client will learn how to forgive and cope with these issues. What is unfortunate in this case is the fact that the other children ended up going back to the parents. Shortly after that reunification, the old ways came back. However, since the client was not there to act as the caregiver for the other children, the oldest sister took over that role. Here the cycle continues. Although the other children were not as open with the school counselor, they need close monitoring just as their bother received in the past. This close monitoring may be able to stop further neglect and abuse from occurring. Additionally, it would be wise to continue monitoring and providing therapeutic services to this client. There may still be some deep seeded issues he will need to deal with. Finally, the client will need help adjusting to his new family and the issues they have brought him, specifically the separation of his adoptive parents. In addition to ensuring that this client is adjusted in his new life, additional support and therapy can monitor the presence of future mental health related problems. Posttraumatic Stress Disorder is often seen in individuals who have experienced abuse. Because of the life situations this client had endured as a child, he is susceptible for Posttraumatic Stress Disorder. If this disorder develops, the client will experience flashback type symptoms. This may hinder his ability to cope with past and future life events. Additional problems associated with Posttraumatic Stress Disorder include impulsive behaviors, insomnia, nightmares, avoidance issues, poor concentration, hypervigilance, and increased startle response. Because Posttraumatic Stress Disorder occurs after the individual experiences the trauma, symptoms may not appear until later in adulthood. Also common in individuals with Posttraumatic Stress Disorder is alcoholism and substance abuse. Again, this client is at a higher risk for these issues because of the genetic component of both alcoholism and substance abuse. A diagnosis of alcohol abuse or dependence includes behaviors that include neglect of responsibilities. Individuals who abuse alcohol also will continue to use despite the fact that they know it is causing problems in their life both physically and socially. With continued therapy and support, the client will be able to work out these childhood issues and therefore decrease the probability of future problems. Continued support will also give the client the skills necessary to cope with life’s stressful events. The client will be equipped with the tools need to deal with his problems in a healthy way as opposed to turning to drugs and alcohol. Continued therapy will also allow the client to work out any feelings he may have regarding his siblings who were sent back to his parents. This aspect was not noted in the case study; however, he may harbor feelings of guilt or regret, knowing that his siblings are still in a neglectful situation. It would also be beneficial to the client to join support groups in order to increase his support system. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington, DC: Author.      

Mcdonald’s vs Burger King Essay

Let’s look at fast food restaurants. When you hear someone say, â€Å"Let’s go to McDonalds or Burger King,† what comes to mind would you consider the Big Mac or a Whopper? Think of how many calories that goes into each one. When you look at the Big Mac your calorie count is, â€Å"540 with 29 grams of fat and 45 grams of carbohydrates. † The Whopper shows, â€Å"670 calories, 39 grams of fat and 51 grams of carbohydrates. †(www. associatedcontent. com) So which is healthier, McDonald’s wins this one. Less calories in the Big Mac than the Whopper even though Burger King promotes flame broil is better and much healthier. When walking in the restaurants of McDonald’s you get the since of not welcomed until it is your turn to order. Looking around the place, it is clean yet not many people stay to eat there. One or two people will sit and chat for a while before leaving and making their order. One thing is true about McDonald’s, if they mess up your order while you are still there, they will make it correctly and bring it to your table nice and hot no matter what it was you ordered. Now for Burger King, when you enter their door the cashier says â€Å"Welcome to Burger King, can I take your order,† this research has been done in several restaurants in the area. Once you have placed your order you are given a number and a cup to fill your drink, by the time you are done filling your drink you food is ready to go. Looking around the restaurant there are a number of patrons sitting eating laughing and joking around with one another so the atmosphere is a warm and inviting one. McDonald’s seems to be more of a get it and go type of place and Burger King was sit for a while and chat. The goals of each restaurant are simple. The customer is first, satisfaction is a must. We all know that it’s not as simple as it sounds. Let’s compare the two, at Burger King’s customers are greeted with a smile when you walk in, when a customer places an order they have a choice of dining in or take it to go. The customer is given an option to say, â€Å"I will dine in or take it to go,† this shows they are given customers a choice of what they want to do. McDonald’s on the other hand, satisfaction is number one also, but you’re not greeted with a smile, sometimes it seems that the cashiers don’t want to work there or they just seem so tired. When placing an order the customer have to wait for at least five minutes before it is ready. Not so good in the fast food world of service, but satisfaction is what they are striving to have. They both share the same goals but one is more of an over all than the other. McDonald’s have a goal of satisfying their customers at 100% but they sometimes fail at making this goal work. How does the public differ in the choices of McDonald’s over Burger King? For one which taste better, which has better quality, would the customer prefer flame broiled over fried. Take a taste test first, McDonald’s signature burger the Big Mac; as the commercial says, â€Å"Two all beef patties, special sauce, lettuce, cheese, pickle and onions on a sesame seed bun. † When the customer orders it in the restaurant, it is in fact, much smaller compared to the advertisement suggest. When doing this research, two out of five people got what they really wanted; the other three had to ask for more sauce and less lettuce. When the order was received, it was sloppy, sauce on the sides of the bun and not on the burger. The taste was satisfactory but if you present something that isn’t prepared right the taste falls short. Burger King’s signature burger the Whopper; â€Å"Beef patty, sesame seed bun, mayonnaise, lettuce, tomato, pickles, ketchup, sliced onions, flamed broiled on a sesame seed bun. † Research shows out of the five customers that were tested at Burger King, each customer got exactly what they ordered and was satisfied with the taste of the meal. One even asked for an extra slice of cheese. Burger King satisfied more customers in the area of taste. Which has better quality of food? This falls very hard when thinking about both restaurants. McDonald’s and Burger King have in fact, had good quality but one out shines the other. As it was stated before McDonald’s Big Mac was served sloppy that was not quality service. In terms of Burger King, the customers were very satisfied with the quality of food and service that they received. Looking at the companies goals is a major difference. Let’s take the Mc Donald’s organization, one hundred percent customer satisfaction. When looking at this goal, it’s not always reachable. When this goal is not met, they will do what ever it takes to fix the problem. The next goal that puts them at a higher standard than other competitors, it’s founded on giving back to the community with the Ronald Mc Donald House and Ronald McDonald Children’s Charities. In each restaurant and drive thru there’s a donation box so money can be placed into helping the charities. So many times there have been full boxes of money given. Over the years McDonald’s has given millions of dollars back to communities in an effort to help children in need of care. Burger King was founded in 1953, the worlds #2 hamburger chain since McDonald’s. All of the burgers cooked at Burger King are prepared by grilling over flamed fire. When looking at how the structure works for them, Burger King doesn’t advertise their products like most competitors. There is no way Burger King can produce more sales than McDonald’s due to their marketing strategy which puts them at a disadvantage with McDonald’s. Where they can improve on this, they can do more advertisement of their products and open more chains around the world. Burger King does offer its â€Å"own in house charitable organizations† and programs which is the â€Å"Have It Your Way Foundation,† which is also a â€Å"US based non-profit corporation to alleviate hunger and disease prevention. (http://en. wikipedia. org) However Burger King also offers Scholarship Programs for millions of high school children across the United States which is in the memory of the co-founder James W. McLamore. This year alone they have awarded more than $1. 4 million in scholarship funds to 1,258 students and they also have four new awards that they give out but the major scholarships includes one King $25,000 and three James W. McLamore Whopper scholarship $50,000. (Burger King Corporation) The interaction with the public for both restaurants is very different. When walking in the restaurant the employees are very busy taking orders. The sense of urgency is upon them to get the food out fast and perfect. Once the order is placed, there is no time to talk however at Burger King, while waiting on your order the manager has time to chit chat with you. Managers make sure that the environment is warm and inviting. The employees that are cleaning around the tables and chairs make sure that they do notice you. There have been times where the employee asks if they could get something more or a refill. This is what customer service should be like. McDonald’s, on the other hand, there is no sense of warmth. Maybe one person may look your way and ask is everything’s alright, but that’s as far as the conversation will go. At both restaurants there is a difference between the employee and manager. They both have different shirts and tags. Sometimes though it could be hard to tell the difference because if you go to the restaurant late at night it’s more lax than the day time hours where you will have employees and mangers playing around but still doing their jobs. One other thing that these companies do, they do hire the less fortunate, meaning people with disabilities. Both companies start with their signature logo and end with their logo, major difference McDonald’s only takes the order. Sometimes it’s hard to understand what is being said over the pa and the order may get mixed up but there is time when getting to the window to fix it. Not all the time at McDonald’s does the employee have the food ready so the customer is asked to pull over and food will be brought out to them? On one occasion, while waiting for the order as the minutes passed by, no order was delivered. The customer had to go into the restaurant to get the order and it was still not what the customer ordered. One would wonder how many times this has happen in the past. Is drive thru really fast and easy? Thinking it may be better to order inside so the order can be done properly. Burger King Employees smile when taking and giving the orders. Even in the drive thru, the smile can be heard over the pa when placing an order. If a customer has to wait on their order thru the drive thru, they are asked to pull around the front and someone will be out with the order. It is never long that you will have to wait maybe two minutes at the most and the food is hot when it is received. There are healthy choices on the both menus, but do customers often choose the healthy choice? Not always. Looking at the choices of the menus: In some states McDonald’s is required to show the calorie count for the customers. On their boxes that the food comes in, there is also a calorie count that the customer can look at and see just how many calories is listed for the choice that was made for the order.

Analyzing video Article Example | Topics and Well Written Essays - 1250 words

Analyzing video - Article Example In the video â€Å"Mediation in action: role-playing workplace dispute resolution | Acas†, the two competitors at managerial position Paul and Kristy required mediation for the sake of their professional efficiency, stability and future progress. They also needed to resolve their disputes so to bridge the gap in their communication. To mediate the situation between these two, Senior Manager Bernard suggested mediation session which was conducted by an external agent, when he was unable to eliminate the strife between them himself. Now, Bernard as a senior manager regards both of his mangers for their distinctive skills. However, he is unable to accept their continual defiance of each other, which adversely impacted on the business in terms of time, money, lack of contracts and reputation (Mediation In Action: Role-Playing Workplace Dispute Resolution | Acas). After individual sessions with Paul and Kristy, Mediator meets them in a joint meeting and sets the ground rules initially to be followed by both. She reminds them both how these mediation sessions should be kept confidential and how they can ask for private chat if something disturbs them. Moreover, she made it clear to both the participants that they have to give ample chance and respect to the other to share his concerns and the listener will not interrupt the speaker. Setting ground rules and agreement on them makes such session more smooth and participants reach to resolutions quickly without wasting time in arguments. Mediator depicts composed and tactful approach for the second step of mediation that is listening and summarizing (Doherty and Guyler, 2008). She initiated the discussion by picking the flashpoint between two; â€Å"Kristy’s delegation handling issue†. Since, it’s directly related to Kristy’s liabilities in office; therefore, she gave Paul a chance to speak out his understanding on the issue,

Contemporary Authors and the Past Essay Example | Topics and Well Written Essays - 2000 words

Contemporary Authors and the Past - Essay Example However, the criticism is that young individuals with severe literary ambitions are no longer concerned in the metropolis or big, as well as rich slice of up-to-date life. This is because such writings are normally met with harsh outrage from contemporary authors and other critics (The Independent, n.d). What is lacking from contemporary fiction is the kind of accounting, which prominent Victorian novelists such as Hoban (1980), Rushdie (1980) and Swift (1983) engaged in, and it was through this that they endeavoured to bring successful novels. Certainly, writing about current issues is one of the hardest things to do. People may think it simple since there are so numerous prominent writers on magazines and newspapers around, and, at its best, modern-day journalism approaches what creative writing can do to elucidate the human condition (The Independent, n.d). ... However, his inquisitive mind and eccentric ways differentiated him from his peers (The Independent, n.d). Also, when he notices a remnant of the old time, he puts in motion a chain of events, which might well initiate the end of the world once more. Written in an outstanding and gratifying language, this is a novel that pays off rereading time and again. Hoban’s book was greatly and favourably evaluated when it was first published, with its language granted exceptional attention. This book is told in a language, which attempts the impractical and attains it (The Independent, n.d). The agreement, then, is that the writing is an extremely good mainstream book, which endeavours to attain marvelous things and it does this. The author writes in a kind of postmodern (contemporary) English, which entirely echoes the bow and spear culture of a primitive world (Hoban, 1980). The novel is a marvel of lexical creativity. Hoban (1980) utilises the resources of historical linguistics to d evelop a language, which no other author has used and yet each and every word contributes to the idea of vernacular corruption and degradation. The medium is, in essence, the author’s message for he keeps a vigour control of his language so that he can develop the societal layout of his prospective inland. Primitive punctuation, elementary spelling, folk etymologies, as well as a simple and frequently crude vocabulary shape the psychic background of the prospective individuals and they show the determination and truthfulness of that truth seeker (Hoban, 1980). Underlying the desire for historical novels is maybe a collective feeling, which literary imagination and fiction are not adequate in themselves to make a book worth reading and

Working Capital Management Essay Example | Topics and Well Written Essays - 3750 words

Working Capital Management - Essay Example The paper tells that working capital for any firm is defined as the amount of money or current assets required by an organization for its everyday running. Liquidity in a business ensures that it remains solvent and that all its operations can be successfully undertaken. Cash, therefore, is a crucial part of the survival of any business organization. For this reason, sound financial management policies are paramount to the success of any business. Working capital management also involves providing finances for investment in the short term assets that are essential for the day to day running of the organization. They include reserve for unexpected costs, pre paid costs like operating licenses and insurance policies. Cyclic or seasonal financial needs should also be met. A clear example is the excessive spending of credit card holders during festive seasons like Christmas, where the banks experience an increase in lending. Good financial management will ensure that the banks can give a s much money as possible. There is also a delicate balance between too much solvency and profit maximization of an institution. Citibank, the principal operating subsidiary of Citicorp are among the biggest financial institutions in the world. Citibank has many international branches especially in south East Asia. In 1983, Citibank’s country manager for Indonesia, Melhi Mistri, was faced with the task of increasing profitability while managing the banks operating capital in line with reviews of its operating budget. He also had the mome

Discussion Essay Example | Topics and Well Written Essays - 500 words - 14

Discussion - Essay Example Thankfully, we live in the United States, where this battle has been fought, and has gained  a substantial amount of ground. Womens rights in the US are equal mostly, with the exception of salary differences between men and women. Unfortunately, in other parts of the world, women are still treated as less superior and some are not even allowed to work. Sadly, this will be a battle I believe will never go away. Yes, you are right. Women’s rights are a critical issue in our society today. Many people do not seem to even consider them because they may think that it is so old fashioned, but I am pleased to see that this issue is important to you. You are also right when you say that even people who aren’t feminists need to get behind and supports these issues because this is simply a matter of self-respect, nothing more. Compared with much of the world, the United States treats women equally and fairly. That doesn’t mean that you should not accept any unfair discrimination against women in the United States because it does still happen occasionally. One example you mentioned was the differences in salary. This is true because the research does show that there is a gender gap in terms of salary. For you own information, this is commonly known as the glass ceiling. There have been many activists who have fought over the years to try to get this barrier removed so women can be treated equally in the workplace, but it is yet to happen for reasons that are still contentious. Many other countries do not afford the same freedoms to their women. You only have to look at most Islamic countries and see that women are inferior to men. These women are banned from doing activities that we take for granted. Finally, you are spot on when you comment that this is a battle that will never go away because there will almost always be resistance to women’s rights from some men. When I was thinking about and researching human rights, I

How Can Training And Development Enhance Employee Performance In An Essay

How Can Training And Development Enhance Employee Performance In An Organization - Essay Example It subscribes to the notion that phenomena and knowledge are â€Å"truths† only if they can be confirmed by the human senses, through deduction and induction methods. Express differently, the major distinctions between these types of knowledge claims are: whilst the goal of postpositivism is determinative for the purpose of verifying an a priori theory, constructivism seeks to understand for the purpose of generating theory; whilst postpositivism tends to reduce all data gathered into a single â€Å"truth,† constructivism ascribes varied meaning as warranted, and; whilst postpositivism employs empirical observation and measurement, constructivism uses social and historical construction (Creswell 2003 6). A scrutiny of the present research question reveals that it essentially requires a constructivist approach of learning because it calls for the researcher to seek an understanding of the effect of certain conditions, i.e. training and development, to the quality of work of employees. At this point, no theory is yet established or needs to be proven. The researcher goes into the research with an open, inquiring mind unfettered by any working theory, and seeks only to form a theory during the course or at the end of the research. The research question also calls for the researcher to discuss and probe into the minds of the respondents who will be engaged in the research to understand how such training and development have improved their performance in their respective work. The constructivist inquiry could be conducted best through the employment of the qualitative research approach rather than the quantitative method.  

Social Entrepreneurship Essay Example | Topics and Well Written Essays - 2250 words

Social Entrepreneurship - Essay Example es mainly address the social needs in the society through offering products and services that aim at meeting the cultural, social and environmental needs in the society (Paton, 2003 p. 89). The bank commenced operations in 1984 providing trade union banking services while observing the founding principles. The trade unions offered provided equity capital of 1.25 million pounds while the Co-operative Bank added 2.6 million pounds to the start up capital. In the first year, the bank operated as a licensed deposit taking institution providing its clients a range of banking services. In the first year, the balance sheet figures in terms of assets grew to over 40 million pounds with the deposits reaching 35 million pounds. The Bank offered a rights issue in 1986 thus enabling more trade unions to buy shares. Fifty-eight trade unions were now members of the bank. After the passage of Public services (social value) Act 2012, Birmingham has experienced the emergence of many social enterprise s. The Act enables the stakeholders to become members of the social enterprises and introduces several tools for the identification of the social impact (Price, 2009 P. 52). The major responsibilities of social enterprises include encouraging community involvement, encouraging of equal opportunities and supporting a green economy. Social enterprises should also encourage sustainability initiatives like recycling and encourage fair trading practices (Doherty & Thompson, 2006 p.40). Social enterprise based organisations have innovative and people-friendly solutions that aim at creating positive change in the society unlike the traditional corporate world that is geared at profit maximisation (Nicholls, 2006 p.18). Most social enterprise based organisations work with poor communities and provides the staff with flexible working schedules. According to the UK department of Trade and Industry (DTI), socially based enterprises have primary social objectives whereby the surplus is reinvested

Marketing essential Coursework Example | Topics and Well Written Essays - 3000 words

Marketing essential - Coursework Example Headquartered in Atlanta, USA, Coca-Cola is one of the world’s most well-known companies. Since inception, the company has grown by leaps and bounds and as of today has business operation in more than 200 countries (Coca-Cola, 2013). Coca-Cola Company is the worlds primary manufacturer and marketer of non-alcoholic beverages and other food items. Of the 400 brands that the company has in its repertoire, 16 of them generate revenue of more than $1 billion every year. Its flagship brand Coca-Cola is literally a household name and is liked by millions of people around the globe. The Coca-Cola Company’s mission is to ‘to refresh the world - in mind, body and spirit, to inspire moments of optimism’. The company attempts to create value and make a difference through its products and actions. (Coca-Cola, 2013). While the company relentlessly pursues its mission, it has developed a set of goals so as to cater to the needs of various stakeholders like people (great place to work for employees), partners (taking care of the interest of vendors, suppliers, and bottlers), planet (sustainability measures), profits (maximizing shareholders returns) and portfolio (building brands that satisfy customer needs). Coca-Cola is in sound financial health. The behemoth registered net operating revenues of $ 48,017 million in 2012, up from $ 46,542 million in 2011. The total assets of the company as of December 31, 2012 stood at a mammoth $ 86,174 million. In addition to the carbonated soft drinks like Coca-Cola, Diet Coke, Coke Zero, Sprite and Fanta, CCGB also manufactures and markets the Oasis still fruit drinks, the Powerade isotonic sports drink and Abbey Well water in Great Britain. CCGB also owns the Schweppes and the Glaceau Vitamin Water brand. SWOT analysis refers to the study of a company’s strengths, weaknesses, opportunities and threats. While the strengths and weaknesses are identified by scrutinizing the

Individual Strengths and Group Process Essay Example | Topics and Well Written Essays - 1000 words

Individual Strengths and Group Process - Essay Example I give a brief description of these techniques as well as the learning’s and improvements that I can get from the same. 1) I have worked as a part of a team of 14 people that was involved in supporting a financial software application in a Fortune 100 company. We are a team that has people from diverse ethnic backgrounds and comprising men and women in almost equal proportions. The team has the responsibility of maintaining a pension funds application and fixing any bugs and issues that are reported from time to time. 2) I lead the maintenance and support team and my experience in people management and leadership abilities are the skills that I bring to the group setting. They have benefited the group in resolving the issues that are associated with team management and group dynamics. The ability to motivate the team and lead from the front by setting an example is one of the key skills that I have brought to the team and this has helped me immensely. I believe that the team has also benefited by my managerial style. 3) I have a tendency to trust my gut feelings more than group consensus. While gut feelings are an asset when taking decisions that involve me, when it comes to taking decisions that involve the group, I believe that the view points of the group must be taken into consideration. The other drawback is that I should listen more and then act. I have a tendency to act impulsively without listening to the other person or the group’s point of view and this has been described as one of my weaknesses by my supervisor. 4) The other members of the group bring their unique and individual view points to the group that brings in the much needed perspective and other side of the debate stance to the issues faced by the group. Because of this, it is easier to balance the both sides and take a measured stance at solving the problems of the group. Further, because of the ethnic mix of the group, there are some added view points to

Introduction to Criminal Justice Essay Example for Free

Introduction to Criminal Justice Essay The federal criminal justice system comprise of federal courts, corrections, and law enforcement agencies. The United States Attorneys is the primary agency taking charge of cases involving the U. S. government as a party and in collecting debt owed to the federal government. The federal judiciary has a Supreme Court, appellate courts, and trial or district courts. Federal law enforcement agencies derive their authority from the U. S. Constitution and federal laws while the state law enforcement obtains authority from the state constitution and legislations. The difference in source of authority, which determines jurisdiction and role, determines whether a criminal case is a federal or state matter. Federal Criminal Justice System The criminal justice system in America today comprise of courts, corrections and law enforcement operating at the local, state and federal level (Samaha, 2006). These tiers of decision-making operate independently according to the scope of their jurisdictions. The discussion focuses on the federal level relative to the local and state levels. The U. S.  Department of Justice comprises the primary criminal investigative and law enforcement agency at the federal level. The Office of the United States Attorneys, which falls under the U. S. Department of Justice, comprise the principal litigators assigned to judicial districts, within which each Unite States Attorney exercise the role as the chief federal law enforcement officer for the United States. The United States Attorneys Office mainly prosecutes cases involving the United States as a party and collect debt owed to the U. S. ederal government as provided by Title 28, Section 547 of the U. S. Code. (United States Attorneys, 2009) The federal judiciary or court system emerged from Article III of U. S. Constitution. This has three tiers of decision-making. At the top is the U. S. Supreme Court comprised of the Chief Justice and eight associate justices handling cases involving important constitutional or federal questions of law that originated in the state or the feder al courts. In the middle is the appellate court, made-up of 94 judicial districts pooled into 12 regional circuits. The U. S. Court of Appeals in every circuit handles appealed cases coming from the district courts or federal administrative agencies as well as handles appeals of special cases. At the lower level is the trial court comprised of the district courts, with criminal and civil jurisdiction. The Court of International Trade and the U. S. Court of Federal Claims are special trial courts. (Samaha, 2006; â€Å"Understanding the federal courts,† 2009) Federal law enforcement agencies derive their authority from the U. S.  Constitution. Article 1, Section 8 provides the power of Congress to enact laws needed in executing governmental powers. The constitutional powers of Congress accords federal law enforcement agencies with the authority to operate. Whenever, Congress enacts a statute, it designates the federal agency responsible for enforcement of this law. The provisions of the enacted laws assigned for enforcement to federal agencies indicate the limit and scope of the authority of the federal agencies. (May et al. , 2008) The difference in the role of federal agents and state or local law enforcement officers lies in the jurisdiction and scope of authority. A federal agent has a wider jurisdiction but with a narrower scope of authority determined by federal statutes. Federal law emanates from the constitution that empowers the U. S. Congress to enact laws at the federal level. State or local law enforcement officers have narrower jurisdiction limited only to the boundaries of the state or locality but with broader scope of authority covering the enforcement of all laws applicable to the state or locality. State/local laws come from the state legislatures obtaining authority from the state constitution. (May et al. , 2008) Investigation or prosecution of a crime is a federal matter when the criminal act or issue are covered by federal law or the U. S. Constitution, the U. S. government is a party, special cases within the authority of the federal law justice system, and other cases within federal question jurisdiction. A crime is under state jurisdiction in cases violating the criminal laws of the state. The state holds broad jurisdiction of various cases but with the exception of those falling under the exclusive statutory jurisdiction of the federal courts. (May et al. , 2008) It makes sense to have dual criminal statutes in the federal and state systems covering the same offense. In case of common jurisdiction over an offense, such as discrimination in employment, the parties can opt to file in case in federal or state courts. There are also ways of distinguishing jurisdiction such as the diversity jurisdiction of the federal courts in cases involving residents of two different states over a controversy amounting to more than $75,000 dollars. (May et al. , 2008) The federal criminal justice system operates independently from state and local criminal justice by having its constitutional and federal statute determined jurisdiction. However, it has links with local and state criminal justice in hearing appeals of cases originating from the state courts on grounds of pertinent issues of law.

Banana Flour Essay Example for Free

Banana Flour Essay The industry is growing at fast rate due to increase in population and purchase power, tastes and preference change. And the supply of feeds from flour by-product as well as availability of cheap noodles grows. Four of the largest millers on the Philippines alone comprise the bulk of potential market for suppliers of fortificants (Vitamin A and Iron), as well as equipments or machineries, and labor in fortification. Over the past few years, different kinds of crisis or problems are reported and felt here in the Philippines and in other parts of the world, one of which is Health Problem or Malnutrition. Today, we are experiencing malnutrition. Malnutrition is the condition that results from taking an unbalanced diet in which certain nutrients are lacking, in excess, or in the wrong proportion the World Health Organization cities malnutrition as the greatest single threat to the world’s public health. Testing and studies show that cassava and potato have an ability to become flour. But it has poor availability because it is tropical root crop. So we decided to make a study about Banana. This study will help us to find the way that the flour or banana flour can be a great help to us. There’s so many fruit in the world and each of them have their uses.

E-tailoring Online: Customer Views and Impacts on Services

E-tailoring Online: Customer Views and Impacts on Services Abstract An increasing number of customers are turning to the Internet to make their purchases, as a vast array of goods and services are now only a mouse click away. E-tailing clothes is even more challenging, with new e-tailers hoping to attract and retain satisfied online customers, are constantly creating new opportunities for them, and in order to do that they need to know what evaluative criteria customers use when selecting an e-tailer as well as what they will purchase online. Past research has provided some insight into what characteristics customers assess whilst making this choice. This report has not been without its limitations. Consequently, the present study utilizes a literature review, qualitative and quantitative research to identify the core customer behavior towards this channel, In addition, results of the analysis show that the type of product on offer and the web attributes (determinants) are predictors of customers attitude toward online shopping for clothing and their perception hence, providing an understanding of how they are responding to the new online buying opportunities. 1. Introduction This research report is divided into 5 Chapters. Chapter 1 is meant to introduce the background of the research area with aims and objectives and focus of the study providing guidelines into subsequent chapters. This then will be followed with Chapter 2 having literature review of the matter giving an insight of the research area that will be referred, compared with the data collection and analysis will be made in Chapter 4. However, Chapter 3 will be discussed prior to the actual data collection as it is necessary to identify Research Methodology to be used for the research. Finally, Chapter 5 will have conclusions and recommendations with any limitations faced and with the mention of area for further research if any. The expansion in electronic commerce (E-commerce) has been phenomenal, with most of todays business transactions being conducted through the Internet. The emergence of this electronic retail (E-tail) market has been extraordinary. E-tailing is also a gaining popularity and changing the retail landscape, it is pervasive in what we thought of it six months ago is probably different to what we think of it today and also what we will think of it in six months time. Customers decision making process has also altered greatly with the introduction of this medium and more so as an alternative channel for shopping. Online shopping concept has already caused a stir in the retail industry in the UK, as more people are opting to buy online due to various reasons, a vast array of goods and services are increasingly being made available now through a click of the mouse, creating a new experience and culture. Many retailers are already delivering high value, personalised products and services at a fraction of the cost thereby making it more low cost and also appealing to the consumers (Birch et al, 2000). The number of consumers shopping online has increased markedly, according to Jardine (1999) people have increasingly become price sensitive and often compare prices of goods both online and offline before making the final purchase, in turn increasing competition amongst the retailers. This is the general overview of the e-tailing concept, as understood b y most of us. However, the purpose of this study is to concentrate on the online clothing market in the UK specifically London, in order to determine predictors of customers purchase intentions for clothing products via this channel. E-tailing of clothing items online has always been debatable, especially since clothing are â€Å"feel-and-touch† products, and cannot be bought without engaging this sensory aspect, unlike other cognitive products like books, computer software, dvds and music which do not really require this. Nevertheless, customers tend to buy more clothing products when they perceive the features of the online store, such as a convenience and secure system of ordering and payment, returns policy, the focus on product display, and the offering of products that have a range of acceptable fits as opposed to a precise fit and most of all choice this are some of the most general attributes a customer considers whilst shopping online for clothes. The attributes that enhance the online experience can be particularly influential for products such as clothing, which generally require physical interaction and evaluation prior to purchase. Web experience attributes can affect early decision making stages (search and pre-purchase evaluation) and influence purchase intent of the customer. With the current fragmented nature of the subject area and to keep up with the rapidly developing technology as well the customer attitudes, the author aims to build on the current body of knowledge, investigating and drawing together the key aspects which influence online shopping for clothes, so as to understand how the customers are responding to the new buying opportunities presented to them by the e-tailers in UK then concentrating on London where the survey was conducted by collecting data from a sample of participants, which aided in exploring the capabilities and further to determine consumer behaviour and customer relationship management p atterns in relation to E-tailing, thus the research objectives being set as: 1. To explore the impact of e-tailing in London. 2. To determine customers attitude towards shopping online. 3. To investigate customers perception of shopping online for clothing in London. In order to achieve the results of the set objectives, the author has explored the determinants the customers consider most important when making a purchase online and to what extent they create an impact on their perceptions. The first hand elements collated from the survey has helped to gain rich insights into customers behaviour and attitudes towards this channel. The secondary data which is covered in the second chapter under the literature review the author here has studied and explained the general E-tailing concept and picked relevant data to help understand the subject matter and provide a better insight into the field of e-commerce, covering a wider area (UK), then narrowing it down to specific location (London) which in turn has helped to achieve the set objectives and later also support the resultant findings in terms of the primary data collected via the survey by the author. 2. Literature Review Xing (2001) stresses that â€Å"The emergence and explosive growth of e-commerce through online trading have ushered in a new era of retail business†. 2.1 The Commercialisation of the Internet The Internet, once a tax-sustained and a government-regulated endeavour, is no longer restricted to non-commercial traffic. The early commercialisation of the Internet, in the mid 1990s gave rise to the e-commerce phenomenon. The Internet population has since grown tremendously, as a result of its opening to the commercial traffic in 1991. Its utilisation has since become remarkably more wide and varied in businesses; the application of internet has grown rapidly over the last several years, due to its contribution of the ever evolving new information technology and its positive gains to the business organisations. Its use apart from being internal its also employed externally and its used more commonly referred to as E-business (electronic business) derived from such terms as e-mail and e-commerce, which is the conduct of business on the Internet, not only buying and selling but also servicing customers and collaborating with business partners. IBM was one of the first organisations to use the term E-business (electronic business) when, in October 1997, it launched a thematic campaign built around the term. Today, major corporations have reconsidered their businesses in terms of the Internet and its new culture and capabilities. Companies are utilising the Web to buy parts and supplies from other companies, to collaborate on sales promotions, and to do joint research, exploiting the convenience, availability, and world-wide reach of the Internet, using it successfully. 2.2 The E-tailing Concept â€Å"The emergence and explosive growth of e-commerce through online trading have ushered in a new era of retail business† says Xing (2001). It was seen as a new channel for sale of products and services along with the traditional channels as well as a market penetration strategy for others. E-tail or E-retail the term, came into discussions or rather its origins as early as 1995, its an addition in the computing subject such as, e-mail, e-business and e-commerce. The business of e-retail has been defined as the sale of goods and services via internet or other electronic channels, for personal or household use by consumers (Harris and Dennis, 2002). Its more efficiently used as a marketing tool, which is integrated into traditional business strategies, and also being viewed as a new marketplace by existing businesses as well as new business ventures as the market place becomes more competitive and unpredictable, due to this, the growth of the electronic retail market has been rapid, significantly expanding reach in terms of people, location and range being variety of information, the World Wide Web has created benefits for both the marketers as well the consumers. For consumers, the Web can provide access to a wide range of products and services with low cost (Bakos, 1997), extensive and tailored information, at home convenience for product comparisons, enhanced interactivity (Cross and Smith, 1995), hence facilitating the formation of virtual communities for users with common interests. E-tailing and E-trading operates in all four of the major market segments; business to business, business to consumer, consumer to consumer and consumer to business. Initially, much direct selling (or e-tailing) was taking place on the internet of computer-related equipment and software, one of the first to report successful sales in the millions of dollars directly from the Web was Dell Computer, there after other businesses started employing the concept in various fields from; Travel bookings, Holidays, Books, Clothing and other accessories, this has particularly grown in the Business to Consumer market segment directly or indirectly as a result of the wide usage of the internet. The Internets greatest commercial advantage is said to be the reduction in transaction cost that directly lowers the prices for consumer (Pavitt, 1997), and therefore E-tailing is said to be a low-cost, efficient way to display merchandise, attract customers, and handle purchase orders (Bellman, 2001). 2.3 Online shopping in the UK Home shopping in various forms has been available to the consumer market for more than 100 years in the UK, paper catalogue being the first and the oldest form illustrated with Victorian ladies and do-it-yourself house kits a lot has changed since, in terms of improvements and choice, then came the emergence of home shopping television, however none has had the influence or the expected impact of shopping, as much as the World Wide Web. E-commerce has grown steadily in the UK since the early 1990s. According to Exley (2006, cited in Haymarket, 2006) consumers have become comfortable shopping on the internet and e-tailing is clearly a part of retails future. He adds that e-tail does not have to replace traditional bricks and mortar stores, â€Å"all retailers need to do is to provide a good in-store experience† (Exley, 2006, cited in Haymarket, 2006). â€Å"Since 2000, Internet shopping has soared by over 5,000% with UK consumers spending an astounding  £200 billion during this period. Internet shopping is clearly the bright spot in the UK retail sector, but this industry is still young and has potential for further growth.† (Tina Spooner, director of information, Interactive Media in Retail Group (IMRG), cited in press release, May 2009). No doubt, online shopping is rising steadily in the UK (from a consumers perspective) as internet access has become cheaper, high street cyber cafà ©s are increasing and Internet service providers (ISPs) have already eliminated subscription fees (Daniel, 2000). Furthermore as technology is set to get even more advanced, hand-held devices have become internet-enabled and nowadays most mobile phones connect to the web (Daniel, 2000). With all the above possible ways of shopping more customers are getting accustomed to the online shopping experience and utilising the new channel. This exc eptional growth of Internet shopping is also driven by greater emphasis on customers efficient use of time, as well as the ever increasing number of computer trained customers, hence giving it a positive outlook and a further opportunity for growth to the existing and perspective e-tailers. A wide range of products and services are available for the customers in the UK to buy online from a variety of retailers, which also gives them a better choice, so why would they go buy anywhere else? Although one reason may be convenience, sadly another is fraud; fraud poses the biggest threat to online shopping (Economist, 2004) but according to Pavitt (1997) consumers fear of shopping online is already resolved by the use of encryption technology. Moreover, the security systems are rapidly improving by the day, further dispelling the notion which is perceived by a majority of people worldwide that online shopping is a risky business. For example, secure digital systems such as encryption tools, digital signatures and the guarantee about security or privacy concern provided by the e-tailers have reduced security inhibitors and thus have increased consumers willingness to visit or purchase from sites (Ah-Wong et al., 2001; Han and Maclaurin, 2002). UK is the second largest e-taling market in Europe like Germany, it combines a large consumer market with internet penetration above the European average (Datamonitor, 2002). There are six leading online shopping companies that dominate the UK e-tailing market. These are; streetsonline.co.uk, Jungle.com, Amazon.com, Lastminute.com, Thomascook.com and Egg.com, all these providing a variety of products and services. What is the future of high street stores when most analysts agree that in five years time, online shopping could be worth  £200billion? This does represent some form of concern to high street stores in the UK as a percentage or it could be of the sales they lose. Nevertheless according to Brewer (2006); cited in Haymarket (2007) the future is brightest for those high street stores that could adopt a multi-channel strategy. However, Murphy (2006); cited in Haymarket (2007) says that â€Å"we have the most vibrant, competitive high street in the world and high street shopping is one of our biggest leisure pursuits. Can high street shopping be our biggest leisure pursuits since they boast to sell a variety of diverse products in-store? It is the refore inconceivable that the future of retail would be solely online†, although the number of customers making purchases online is also on the rise in the UK as mentioned earlier in this report. 2.4 The extent to which e-tailing builds relationships The impact of e-tailing will be felt differently and at different times by various retailers. In the context of buyer behaviour preferences (Daniel, 2000) says that e-tail is a transactional-sales medium rather than a relationship-building medium which means that e-tail cannot substitute personal contact such as customer service advisors, that makes it the most critical differentiation aspect to high street stores today. This emphasises the need further research on the customers perception of e-tail, i.e. to what extent does e-tailing build relationships? If empirical research suggests that e-tailing is a transactional sales medium then ultimately there may be an opportunity for e-tail to focus building relationships with customers that will create the need for further research on how e-tail may be able to become a relationship-building medium. Personal contact with highly trained and motivated salespeople, the service factor is still the critical differentiator for such businesses, and on-line experiences have yet to match that or offer a suitable counter value (Quelch, 1999 cited in Maruca, 1999). As Pavitt (1997) states that the impact of e-tail on high street stores may result in changes on three key fronts; â€Å"change in the nature of product offerings, customer buying patterns and its place in the value chain†. The changes in product offering may alter as a result of advances in digital technology. For example media products delivered via the internet or newspapers being published electronically, that would be a direct impact on high street stores (Pavitt, 1997). There is lack of empirical evidence to show what customers perceive of digital medium against physical goods, as an simple example, would customers prefer buying a DVD from a high street store, so as to get a feel of the physical aspect of this product as well as more information from the back cover of the DVD case, or from the Internet where information on the product is limited in two dimensional form. â€Å"There will be a great deal of change in the value chain as well due to shrinkage in distribution channels†, (Bellman, 2001). E-tailing eliminates traditional chain of wholesalers, agents, and other intermediaries thus creating a new distribution model focusing on manufacturer to consumer direct that implies a great potential for savings (Bellman, 2001). Today, majority of the manufacturers do not want to take the responsibility of dealing with single customer queries, which is one reason why they sell their products through intermediaries even on the Internet. With lack of evidence it still remains to be investigated as to what extent is the internet an intermediary? Another common question which arises in this case is; do e-businesses have any storage for products they advertise or do they order them directly from the manufactures or other traders as required? However, this can also be different in the case of businesses which use internet as a secondary channel for sell or distribution of their products, which they also sell in their physical store. Another issue that arises is to investigate potential shoppers perception in relation to price. Smith et als (1999); cited in Lii and Lee (2005) indicated that online shoppers believe that online stores enjoy a cost advantage over traditional channels in terms of administrative cost, overheads and transaction cost. These features of the online retail channel add to the perception of online shoppers that prices generally tend to be much lower online than that of the high street stores. Considering this then, do customers shop online because they perceive it to be cheaper? If so then how and in what w ays is online shopping cheaper compared to the high street stores where lots of products are reduced at competitive prices even at times with offers such as buy one get on free or a second product at half price, are always there. Is price an issue of concern or is it about building relationships? Would customers be willing to pay that extra price in exchange for good service, remains to be investigated? Good service may be classed by online shoppers such as providing a tracking system for their ordered goods, free return policy and delivery of the goods or a full money back guarantee on items that customers return which is in place with most e-businesses today. With regards to customers online shopping behaviour, Brown (2000) states that a survey by BT found out that consumers choose well-known brands when shopping online and those consumers want to be served immediately, be remembered and treated as individuals. Therefore, in what ways can e-businesses build relationships? According to Kalyanarm and Winer, (1995); Chandrashekaran, (2001); cited in Lii and Lee (2005) prior studies have revealed that in the off line retail channels, customers may use the advertised original price as a frame for reference to assess the accompanying sale price. The resulting price comparison between the original price and the sale price makes the price promotion more appealing (Biswas and Blair, 1991; Grewal et al, 1996; cited in Lii and Lee, 2005). On the other hand on line retailing enables potential customers to have quick and easy access to price and other product attributes and information necessary for price evaluations. An example is amazon.co.uk websit e. The Internet has empowered on line shoppers to better detect price discrepancies and bargains (Balasubramanian, 1997; Bakos, 1997; Hoffman and Novak, 1997; cited in Lii and Lee, 2005). Today Majority of e-tailers attract customers through promotion codes normally available through advertisement and marketing media from which customers, can usually claim some money off or some percentage of discount on their online shopping. What remains to be assessed is whether the promotional codes attract new customers and also retain existing customers to shop online? If e-tailers start providing regular promotion codes to new customers as well as regular customers with this, then will it add up to building a relationship? 2.5 Customers general online shopping preferences in the UK On the basis of the objectives of this research, its crucial to investigate customers e-tail shopping preferences in the UK in general first, since ultimately perception leads to action. â€Å"When consumers are confronted by new forms of retail channels such as on line shopping, they may decide whether the difference between the on line shopping and off line shopping is significant to them. If the difference is perceived to be insignificant, customers may classify the two retail channels as the same. On the other hand, if the differences are perceived as significant, customers may classify the two shopping channels as different and make their purchase decision differently† (Lii and Lee, 2005). â€Å"Perception involves the process of categorization, and people tend to place new experiences into existing classifications of familiar experiences† (Monroe, 1990; cited in Lii and Lee, 2005). Late night shopping in the UK is fast becoming a way of life and a new culture, since for many people 24-hour high street shopping is invaluable as it allows them to fit it around their lifestyles, this is very common in the larger cities like London where this sort of service fits in well with the metropolitan lifestyle whereby time is crucial, however having said that, its also being almost equally favoured by people living in smaller towns or suburbs. The changes occurring in buyer behaviour patterns are alarming to high street retail stores as more and more people are beginning to work partly or wholly from home and they may prefer their goods bought online to be delivered at home, this is also rapidly picking up for supermarkets where the consumers prefer their grocery as well as other items shopped on line to be delivered at their doorstep (Haymarket, 2006). Whatever may be the case, Cottam (2006, cited in Haymarket, 2006) says that high street retailing is facing stiff competition with on line ‘anytime culture, meaning that customers are shopping 24/7 and therefore even high streets supermarkets such as Asda and Tesco have also launched 24-hour stores. Customers perceptions about 24/7 shopping remain to be investigated, since some high street supermarkets that tend to provide 24/7 services are closed on Sunday afternoons due to Sunday trading laws, but this has also changed in recent years. Once more it raises the question, what are customers perception of 24/7 culture in relation to the internet and high street stores, a fair example to portray, the 24/7 concept proved to be costly, in comparison to profitability against cost, for a superstore like Sainsburys as Sainsbury failed in its attempt, even though it believed it had the winning formula (Haymarket, 2006). The reason behind the failure was that Sainsburys could not attract enough customers as there is no guarantee that a fair percentage of existing or new customers will change their habits to take advantage of 24-hour shopping (Haymarket, 2006). Indeed this is a lesson for others (organisational learning) and thus most retailers are being cautious in their approach to 24/7 services. Bearing this in mind customers are constantly taking advantage of such facility and are trying or even getting used to shopping around the clock says Gladding (2006, cited in Haymarket, 2006). Analysts argue that 24-hour retailing is less likely to grow beyond its current levels as retailers have raised little awareness of the fact, hence stores such as Asda and IKEA are being cautious about this approach by advertising their long opening hours in the form of outside signage and flyers (Haymarket, 2006). The key question that arises from this scenario is the customers perception of the availability of 24/7 online shopping versus the high street 24/7 timings. Do customers really want go to shopping at high street stores and supermarkets at night (freely) compared to doing online shopping at night? Security is another issue that could be a vital sign of failure for high street stores or supermarkets to remain open 24/7 and be able to achieve their budget. Depending on the type of product, Andrew and Currim,(2004) have highlighted some key characteristics of customers shopping on line, despite the additional aspects. They say that consumers shopping online for products such as groceries differ from those who shop in high street stores claiming that on line grocery shoppers tend to be more frequent, heavy shoppers, less price sensitive, prefer larger sizes and do more screening on the basis of brand names. Alternatively, Morganosky and Cude ,(2000) suggest that convenience is the main motivation for on line shoppers, and according to Keh and Shieh,(2001) on line shopping is ideal for time-starved customers such as couples with two careers, children, and above-average income who want to spend time with their families instead. These suggestions are valid and can be applied to the reasons for consumers behaviour towards shopping online, however it also differs to the type of market and the products on offer. Hence, for those people, conven ience is more of a priority than price stresses, Keh and Shieh, (2001). Also Professionals, working women and single independent hard working individuals are just some of the people who do not have time on their hands and their perceptions of online shopping especially for items such as grocery remains to be determined. Keh Shieh, (2001) simply claim, with being deficient in practical evidence, that such customers dislike grocery shopping and only those with busy schedules will consider on line purchasing as a viable option. Online shopping may save time and money as the frustration of dealing with children at a store or supermarket that involves pushing carts up and down the aisles, waiting in long lines at checkout counters, and finding parking spaces, could be eliminated, Keh Shieh,(2001).Whilst on the other hand, as more people today having the opportunity to â€Å"surf† from their offices, they are more likely to shop during office hours and thus may prefer to collect their online shopping at ‘convenient stores on their way back home (Pavitt, 1997). Vaughan (1999); cited in Jardine (1999) head of consulting at Retail Intelligence says that â€Å"consumers might do their main shopping on the internet once a week but will still need to stock up on fresh foods locally† and this is the alternative method that supermarkets have taken by opening ‘convenience stores such as Tesco Express, Sainsburys Local, and MS Simply Food, (Jardine, 1999). According to Lii and Lee (2005), their study on examining customers perception of shopping on line suggests competitive pricing being the main reason. It allows them to compare prices of products more quickly and easily than when shopping in stores. (Korgaonkar and Wolin, 1999; Ernst Young, 2001; cited in Lii and Lee, 2005). According to the author, Mysupermarket.co.uk is a classic example; The website allows registered shoppers to compare their online shopping from high street supermarkets in the UK which are Tesco, Asda, Sainsbury and Ocado which is fully online based. Furthermore it allows users to switch at a click if they decide to change their preference to the cheapest supermarket. The problem associated with this is that it may be time consuming going through the tedious process of comparison because consumers may dislike switching from their preferred supermarket. In the authors view high street supermarkets also offer this service. A good example is that of Sainsburys supe rmarket where there is often a price comparison sheet placed next to their own shelf edge price tags showing their prices as compared to Tesco and Asda. If not then Sainsburys have opened small kiosks often located towards end of an isle where the customer advisor can compare their prices for customers with other competing supermarkets and if their prices are high then they do price match or sell the item even cheaper. This shows that the high street physical stores are also doing their best to match the benefits of on line shopping. Another factor that may drive away consumers from shopping on line is transportation cost. Bellman (2001), says that growing numbers of e-tailers are eliminating these costs as they find that customers often cancel orders after going through the entire ordering process and then considering the transportation cost being high, and this may be the key factor that drives potential customers away. The other fear of shopping online is privacy. Most web users refrain giving out their details, especially data in the form of credit card details as they fear exploitation of their privacy (Bellman, 2001). Insufficient product information on screen also contributes to decline of purchase. Apart from this, all secured websites do have a ‘time-out function where user sessions are based on time limits. If ‘time-out occurs, customers risk losing their entire shopping basket, which is quite frustrating from a customers point of view. These are some of the most common factors which may keep away customers from shopping online and reason their preference to shop in high street stores simply because they are well aware of the location, store layout, product selection and return policies as well as the stores reputation (Greenbury, 1999; cites in Maruca, 1999). Online e-tailing has a great and growing future, but the high street is still an important destination for customers. The limiting factor of e-businesses could be, a simple example, such as one cannot buy a piece of fruit via shopping online but can do so from a store. Furthermore, there is no empirical evidence to justify what drives customers to shop on line instead of high street stores, ultimately questioning what customers online shopping preferences are? 2.6 The E-tail clothing sector in UK Fashion is a sensitive and rapidly moving market which is growing at a faster pace in the UK, in comparison to its other European counter parts. Shopping on line for clothing products is also fast gaining popularity in the UK. Although buying over the Internet remains small in comparison with buying through the traditional channels, such as the brick-and-mortar physical stores, it is growing and clothing is a substantial portion of the e-tail sector in the UK. The online clothing sector caters for almost all segments of the UK market starting from the low cost value clothing to high end designer clothing including bespoke tailoring to couture clothing, the choice is unlimited and the options ever increasing. One can buy a single handkerchief to a full suit online, even clothing and accessories for all age ranges are available, whereby the customer can buy clothes for new born babies to clothes for senior citizens, therefore making this shopping Diabetes: Questions and Answers Diabetes: Questions and Answers DIABETES Diabetes Mellitus The medical name for diabetes mellitus comes from the Greek word that means to siphon and the Latin word that means sweet like honey. Diabetes mellitus is the name given to a group of conditions where there is too much glucose in the blood. It affects approximately 3% of the population. There are currently 1.4 million people with diabetes mellitus in the UK and it is expected that by 2010 that there will be a further 1 million. It costs the NHS 4.9 billion a year and affects a million people without them even knowing that they have it. (Devendra et al 2004) RELATED BIOLOGY Which organ is involved in the regulation of Blood Glucose Levels? The pancreas. Where is it located? Retroperitoneally, within the curve of the duodenum and with the tail extending to the posterior surface of the spleen. What type of tissue is it made up of? Primarily glandular tissue that has both endocrine (Insulin) and exocrine (Pancreatic digestive enzymes) functions. Which area of this organ is responsible for producing the hormones involved in the regulation of blood sugar levels? The Islets of Langerhans What are the main functions of insulin? To reduce the levels of blood sugar by facilitating the uptake of glucose from the bloodstream into the cells. It increases the rate of glycogen synthesis in the liver It promotes the synthesis of fatty acids in the liver It inhibits the breakdown of fatty acids in adipose tissue It stimulates the uptake of amino acids It increases cell permeability to potassium (after Wills C et al 2003), What type of substance is insulin made of? Circle the correct answer. Carbohydrate Protein Fats Name the calls that produce the hormone glucagon. Alpha cells What are the main functions of glucagon? An insulin antagonist, it raises blood glucose levels by increasing hepatic glycogen breakdown. It activates hepatic glyconeogenesis It enhances lipolysis of triglycerides One of these hormones has a Catabolic action and the other an Anabolic action. State what these terms mean and identify which hormone falls into which category. CATABOLIC Catabolism is the breakdown of complex biological molecules into smaller component ones Glucagon ANABOLIC Anabolism is the synthesis of complex biological molecules from simpler components. Insulin What are considered normal limits of blood sugar readings? Fasting blood sugar 3.0 to 6.1 mmol/l (Client note: this is variable I have quoted WHO figures – check what your tutor recommends and add it here!) Those with levels of 6.1 to 7.0 mmom/l are said to have impaired glucose tolerance (WHO 1985) CLASSIFICATION OF DIABETES MELLITUS State the 4 main categories. To the client: this is a loaded question. There are many different classification schemes. I quote the categories as defined in RECD 1997 Type 1 diabetes mellitus Type 2 diabetes mellitus Gestational diabetes mellitus Secondary diabetes mellitus – includes: Genetic defects of beta-cell function Genetic defects in insulin action Diseases of the exocrine pancreas Pancreatitis Trauma/pancreatectomy Neoplasia Cystic fibrosis Hemochromatosis Endocrinopathies Acromegaly Cushings syndrome Glucagonoma Pheochromocytoma Hyperthyroidism Somatostatinoma Aldosteronoma Drug- or chemical-induced Vacor†  Pentamidine Nicotinic acid Glucocorticoids Thyroid hormone Diazoxide Beta-adrenergic agonists Thiazides Phenytoin Alfa-interferon Infections Congenital rubella Cytomegalovirus Uncommon forms of immune- mediated diabetes Other genetic syndromes sometimes associated with diabetes Down syndrome Klinefelters syndrome Turners syndrome Wolfram syndrome Friedreichs ataxia Huntingtons chorea Lawrence-Moon Beidel syndrome Myotonic dystrophy Porphyria Prader-Willi syndrome (RECD 1997) Diabetes mellitus can be due to a deficiency in insulin synthesis, secretion and also in some cases resistance. It is also thought that some diabetics may have a combination of both. State 5 causes of Primary Diabetes Mellitus [aetiology]. Primary Diabetes Mellitus is subdivided into Type 1 and Type 2 varieties Aetiology of Type 1 is multifactorial. It is auto immune and trigger factors can be genetic or environmental Environmental causes include exposure to Coxsackie B virus, Rubella virus and Cytomegalovirus and exposure to cows milk. Aetiology of Type 2 is also multifactorial. It includes genetic factors and environmental factors including: western diet, lack of exercise, obesity and hypertension (Todd W et al 2000) NB Causes are still unknown, the above are thought to be trigger factors. State 4 causes of Secondary Diabetes Mellitus. Causes of secondary Diabetes Mellitus. There are several types of secondary Diabetes Mellitus including: gestational diabetes malnutrition-related diabetes pancreatic diseases causing diabetes endocrine diseases causing diabetes drugs and chemicals causing diabetes genetic conditions causing diabetes Causes depend on the variety but include pregnancy, pancreatitis and various drugs including: steroids thiazide diuretics phenytoin diazoxide streptozotocin Pancreatic diseases can cause Diabetes Mellitus including: acute and chronic pancreatitis pancreatic carcinoma cystic fibrosis haemochromatosis Disease processes can also cause secondary Diabetes Mellitus including: acromegaly Cushings syndrome glucagonoma phaeochromocytoma Complete the following chart by using the recommended textbooks to compare the two main types of Diabetes. TYPE 1 TYPE 2 Age at onset juvenile ( % of all cases about 10% about 90% Acute/insidious acute insidious Body build lean obese Genetic link high low Prone to ketoacidosis yes no Autoimmune Disease yes no Treatment insulin diet, oral hypog’s (Harris M 1995). What age group in the general population has the highest incidence of Type 2? Typically the 55-75 age range (Harris M 1995). Certain groups in the general population have an increased risk of developing Type 2 and currently Diabetes UK is promoting a campaign to identify those most at risk earlier, so that they do not develop the major complications associated with this chronic disease. This is called the Missing Million Campaign. Names these â€Å"At Risk† Groups 1. History of Heart Disease 2. History of Stroke 3. Obese (BMI>30) 4. Over 50s 5. Over 40s if from African Caribbean or Asian backgrounds PATHOPHYSIOLOGY / CLINICAL FEATURES DEFINITIONS Define the terms:– Gluconeogensis Biosynthesis of glucose from sources other than glycogen Glycogenolysis Oxidisation of hepatic glycogen into glucose Briefly describe how insulin deficiency / absence can cause the above processes to occur. Insulin deficiency and/or low glucose levels promote the secretion of glycogen Glucagon promotes the activation of the enzyme adenylate cyclase in the liver which triggers glycogenolysis. This is exactly the opposite process to gluconeogenesis and is mediated by a number of enzymes, the most significant being pyruvate kinease Clinical Presentation – Complete the following When blood glucose levels arise above a certain amount the renal threshold in the kidneys is exceeded and glucose spills over in to the urine. This is called glycosuria. This excess glucose sucks up the water so that it can flow from the body; this is called. Large amounts of urine are excreted. This is called polyuria. Excessive thirst is called polydipsia. Excessive urination can result in lowered blood pressure and shock. Blurred vision can be caused by fluctuations in the amount floaters and water in the lens of the eyes during periods of dehydration. This is called osmotic myopia of the lens. Cells are not able to access glucose so they do not receive any fuel and as a consequence cannot produce energy. This triggers the brain to send a message of hunger. This excessive hunger is called polyphagia. Lack of energy makes the individual feel tired and weak. Other sources of energy are sought. Fat stores are broken down to provide energy. This may result in ketosis. Breakdown of fats results in the production of ketone bodies which are excreted in the urine. These are acidic and alter the blood PH. There is a sweet smell of ketones on the breath. This is called ketotic respirations. Weight loss also results. Breakdown of protein stores results in muscle wastage. Skin infections are common e.g. Staph boils, erysipelas . Excess glucose suppresses the natural defence mechanisms and the action of the lymphocyte* cells. Electrolyte imbalances occur. The electrolyte potassium affects cardiac muscle causing arrythmias if deficient. Urea and electrolyte imbalances also result in the following symptoms 1. Dry mouth 2. Thirst 3. Muscle weakness 4. Lethargy 5. Cardiac arrythmias. Numbness and tingling in the feet and cramps may result from peripheral neuropathy. Client Note (*)– this is debatable – your tutor may have a specific answer in mid for this one The recommendations of the W.H.O â€Å"Definition, Diagnosis and Classification of Diabetes Mellitus and its Complications† were formally adopted in the UK on the 1st June â€Å"2000. The key recommendation, with regard to diagnosis is that fasting plasma glucose should be lowered from 7.8mmol/L to 7mmol/L. What is an OGTT? The Oral Glucose Tolerance Test In the oral glucose tolerance test the patient, after fasting for 15 hours, drinks 75 g of glucose in 300 ml of water, over 5 minutes. Blood glucose is measured before the drink and after 30, 60, 90 and 120 minutes. Urine is collected before the drink, and after 60 and 120 minutes. Before the test, for a period of 6 hours, the patient should avoid smoking and drinking coffee. There is a normal glucose tolerance if the venous plasma value is less than 7 mmol/l after the 2 hour period, If after 2 hours after the glucose load the value is between 7 and 11 mmol/l, then there is impaired glucose tolerance. If glucose is greater than or equal to 11.1 mmol/l this is diagnostic of Diabetes Mellitus OTHER TESTS / SCREENING PROCEDURES What is an HbA1c Test and why is it carried out? This is a measure of glycosylated haemoglobin in the blood. It is a longer term measure of the degree of blood glucose control. (DCCRG 1993) NICE target is 6.5 7.5 HbA1c When would Urea and Electrolyte levels and Blood Gases be tested? Normally only if metabolic imbalance is suspected, dehydration, renal involvement or occasionally as a screen for end-organ pathology (kidneys). U’s + E’s may be requested as part of a monitoring procedure. Blood gases may be useful if severe ketoacidosis is present. When would a Full blood count, specimen check and chest X-rays be carried out? This is more likely to be done as a screening or monitoring procedure (FBC or Urinalysis) unless there was an obvious clinical reason for doing them such as suspected anaemia etc. A CXR would be less likely to be carried out unless pulmonary or cardiac pathology was suspected (Client: this is contentious – as different clinicians have different rationales for these investigations.) When would and ECG and Lipid levels be checked? ECGs are likely to be checked on diagnosis, as a monitoring procedure or if arrythmias have been detected. They may also be done as a baseline investigation, with hypertension or if cardiac involvement is suspected. Lipids are very likely to be abnormal in Diabetes Mellitus. They would be checked as a monitoring investigation at most visits. (DCCRG 1993) When would a neurological assessment and inspection of the lower limbs be carried out? Peripheral neuropathy and vascular impairment are common sequelae to Diabetes Mellitus and this would be actively considered and evaluated at each monitoring visit. Probably at least twice a year or more frequently if indicated. (DCCRG 1993) Why are protein levels checked? Proteinuria is a good indicator of diabetic nephropathy. Urine protein should be checked at every monitoring appointment. Serum proteins are less sensitive but if renal pathology is established then it may be a useful investigation. (DCCRG 1993) When is urine checked for ketones? In the presence of dehydration, clinical suspicion of ketonuria, pregnancy and as a monitoring procedure. (DCCRG 1993) When would an eye inspection / photography be carried out and why is this done? Retinopathy is a potent cause of visual impairment and commonly found in the diabetic state. It is commoner with poorly controlled Diabetes Mellitus and Type I diabetes mellitus. It is one of a number of ophthalmic complications seen with diabetes and should be actively screened for at every routine visit. (DCCRG 1993) Why would a diabetic require having their blood pressure regularly recorded and what value is recommended? Hypertension is a common cardiovascular complication of Diabetes Mellitus and is an independent risk factor in Type II diabetes mellitus. The presence of hypertension and Diabetes Mellitus coexisting in the same patient will increase the overall morbidity risk of both cardiovascular disease and cerebro-vascular accident. A blood pressure reading below 130/85 mmHg is an ideal goal for most people with diabetes who dont have kidney complications, but some authorities may recommend an even lower blood pressure goal (below 120/75 mmHg) for people with diabetes who have kidney complications. (DCCRG 1995) State the main complications Short-Term Hypoglycaemia, dizziness, lethargy, impaired conscious level – drowsiness. Hyperglycaemia, nausea, headache, malaise, ketosis. Coronary heart disease, Cardiovascular disease (macro- microvascular disease) Retinopathy which can lead to blindness Nephropathy, which can lead to kidney failure and the need for dialysis Neuropathy which can lead to, among other things, ulceration of the foot requiring amputation Microvascular Retinopathy, Nephropathy Neuropathy These are generally related to HbA1c levels with the highest incidence of complication occurring when HbA1c levels are above 12% Atherosclerosis Arteriosclerosis Both processes can lead to : heart disease stroke peripheral vascular disease (Stratton I et al 2000) What are the SIGN Guidelines and name those that relate to Diabetes. A set of guidelines originally drawn up by Scottish Intercollegiate Guidelines Network. They include: visual impairment (SIGN 4) pregnancy (SIGN 9) children and young people (SIGN 10) renal disease (SIGN 11) foot disease (SIGN 12) cardiovascular disease (SIGN 19). Treatment- Give Principles   Type 1 Always insulin dependent. Active treatment involves titrating insulin dose against glucose levels and then maintaining levels by manipulation of the insulin regime Constant monitoring by either patient or physician Constant vigilance for complications Type 2 Depends on cause, but in most cases treatment involves lifestyle modification, weight loss, dietary carbohydrate restriction. If not successful then progression to oral hypoglycaemics and occasionally to insulin. Constant monitoring for the presence of complications Reduction of secondary causes of complication i.e. cessation of smoking. INSULIN Insulin was identified as a substance that prevented diabetes in the early 1890’s. Banting and Best extracted insulin from the pancreas of a dog in 1921 and the first human received a crude extract of insulin from the pancreatic glands of cattle in 1922. Over the years there have been many advances in the synthesis of insulin. Insulin is a protein. Insulin injections are vital for people with Type 1 diabetes as they are unable to produce insulin them selves and also for many with Type 2 diabetes whose condition has progressed to a point where tablets and diet cannot control it adequately. The aim of this treatment is to ensure that blood glucose levels are maintained at less that 6.5 mmol/l. (Client: see previous comments) Name 4 factors which influence control 1. Weight 2. Severity of disease process 3. Diet 4. Level of exercise (Wing RR, et al 2001) There are a variety of insulins available on the market. The two main sources are animal and human. How is human insulin produced? By recombinant DNA technology inserting human genes into bacteria such as E.coli which then produces insulin in commercial quantities. The majority of diabetics are now on Human insulin but unfortunately some people are still required to take animal insulin. Many drug companies are wishing to phase out animal insulin and at present Diabetes UK is campaigning to maintain these. Why does insulin have to be given by injection? Being a protein it cannot be given by mouth as it would be denatured in the gastro-intestinal tract. What other route is being researched as an alternative? A great deal of research has been lavished on alternative modes of drug delivery. Transdermal routes do not give reproducible and consistent blood levels. Oral insulin has not been a possibility in the absence of a specific peptide carrier system that would work in the gut. Nasal administration has been tried, but there was low bioavailability and absorption enhancers were needed, in addition the clinical effect was only over a very short period. Pulmonary routes appear to be promising but we already know that the pulmonary route is comparatively inefficient and requires ten times the amount of insulin to achieve the same clinical effect. Initial clinical trials show no side effects and research is currently continuing. (Heinemann L 2001) SIDE EFFECTS Initially on the commencement of insulin people may experience sensitivity around the injection site. How would you recognise this? This is a form of allergy. It can be local, in which case the local skin becomes red and itchy at the injection site. It may (rarely) be systemic giving rise to a uticarial reaction, tachycardia and tachypnoea. Very rarely a patient may experience anaphylaxis. Symptoms of hypoglycaemia may occur if too much insulin is injected or if not enough carbohydrate is consumed or if there is increased exercise without taking extra food. Hard lumps under the skin may occur at injection sites if they are not rotated. What is the correct medical term for these? Lipodystrophy The number of units prescribed is calculated depending on time of day, age, weight and lifestyle. Typical dose is 0.7-1.0 units per Kg of body weight. WARNINGS Insulin should never be administered in cases of HYPO. The body may get used to low levels of blood glucose and therefore the warning signs for HYPOs are reduced. Individuals who have lost these may be advised to raise their blood glucose levels slightly for up to 3 months to resensitise themselves to symptoms. Some people have also found that they have lost some or all of their symptoms of HYPO when transferring from animal to human insulin. Insulin dosages may have to change if there is disease of the adrenal pituitary and thyroid glands and also in the presence of liver and kidney disease. Taking of steroids will increase the insulin requirement. During illness, puberty or emotional trauma glucose levels can become elevated and therefore insulin doses require to be adjusted and more regular blood sugar monitoring is essential. During pregnancy insulin requirements may decrease in the first trimester and increase in the second and third trimester. The following drugs may increase blood glucose levels and therefore lead to a need for more insulin – Steroids Contraceptives Asthma Inhalers Some drugs lower blood glucose levels and therefore result in a reduction in insulin. These are:- Aspirin Beta blockers Mono-amine oxidase inhibitors. There are four categories of insulin. Give an example of each. Very short acting [ANALOGUE] – e.g. Humalog. Short acting [SOLUBLE, NEUTRAL] – e.g. Actrapid, Human Velosulin. Medium and long acting [ISOHANE, PROTAMINE ZINC] e.g. Human Insulotard. Combination of short and medium acting [MIXED, BIPHASIC] e.g. Human Mixtard. Who would most likely be prescribed very short acting insulins? The very unstable or out of control diabetic. Children more likely than adults. How long before a meal does short acting insulin require to be injected? Depends on type. Sol. Insulin starts working within 30-60 mins and lasts about 6-8 hrs. Other types such as Insulin aspart and insulin lispro both start working within 15 minutes and last for up to five hours. The glucose rise after a meal typically begins within about 15 mins so the insulin should ideally be in the system to counteract it. How often daily would you require to take the following insulins:- Short acting – about 2-4 times a day( when stable) Medium acting – about twice a day Long acting – Once (or perhaps twice) a day These answers depend on the age and size of the patient, as well as the severity of the disease process. Why is short acting insulin sometimes given with medium acting insulin? To give a smoother blood glucose profile and also to â€Å"fill in the gap† before the medium acting insulin becomes biologically active. Where should insulin be stored? In the fridge, but not frozen. Briefly discuss the types of equipment that are used to administer insulin? Commonest is still the disposable insulin syringe. Syringe should always be calibrated to match the insulin type. Most are U-100 now. Other options include the pen devices (expensive but convenient and largely â€Å"fool proof†). Jet injectors are occasionally seen, but not very common. In hospital surroundings insulin pumps (drivers or infusers) can be used. Ambulatory subcutaneous pumps are increasingly used to deliver continuous infusion. Very expensive but arguably capable of producing the best control. (HSG 1997) What advice would you give to a diabetic who is planning to go abroad on holiday with regard to their insulin? Take plenty with you as your brand may not be available abroad. Make sure you can keep it refrigerated. Run your blood glucose levels slightly higher than you are used to a) because of probable increased exercise and b) to reduce the risk of Hypo whilst away from home. Be extra vigilant with the blood sugar monitoring. Strange diet may have unexpected consequences. ORAL HYPOGYCAEMICS Below are the main categories of drugs. Give an example of each, including daily dosage and side effects? Sulphonylureas Chlorpropamide 250 mg (100 mg in the elderly) This is a very long acting drug, usually taken once daily with breakfast. Alcohol may cause flushing to the face. Biguanides Metformin Start at 500 mg twice a day or 850 mg once daily. The maximum daily dose is 2550 mg given in three divided doses Gastrointestinal side effects are a common occurrence in people taking metformin. Problems often include bloating, flatulence, nausea, stomach cramps and diarrhoea Occasionally a metallic taste in the mouth. Rare complication lactic acidosis (Knowler WC et al 2002) Prandial glucose regulator Repaglinide 0.5 to 4 mg with each meal Occasional gastro intestinal side effects (Bokvist K et al 1999) Alpha glucosidase inhibitor Acarbose 50 mg then titrated against clinical effect. Flatulence soft stools or diarrhoea. Glitazones [new drug] Rosiglitazone 4mg as starting dose increasing to 8mg if required Possible toxic effects on the liver (theoretical rather than practical) (Park JY et al 2004) ACUTE COMPLICATIONS The most common is Hypoglycaemia. It results from an imbalance between glucose intake, endogenous glucose and glucose utilisation. A decrease in the blood glucose level normally leads to stimulation of catecholamine secretion. Identify 5 causes. Insufficient carbohydrate intake Excessive carbohydrate utilisation (exercise) Intercurrent acute illness Overdose of insulin Other illnesses (viz glycogen storage diseases) Alcohol Name 8 clinical features that the patient experiences. Pallor Shaking Perspiration Fatigue A feeling of weakness Rapid heartbeat (Tachycardia) Hunger Agitation Difficulty concentrating Irritability Blurred vision Temporary loss of consciousness Confusion Convulsions Coma. What would be given in order to treat it? Depending on severity. If minor, warm sweet (glucose containing) drinks If major, IM Glucagon. Monitoring essential until fully recovered. What is ketoacidosis? A clinical condition almost invariably associated with low insulin levels. As a result, the blood glucose levels rise and the intracellular glucose levels fall. This requires the metabolism at a cellular level to be fuelled with fat derivatives rather than carbohydrates and this produces acidic ketones. These ketones normally require the presence of insulin for their catabolism. In its absence, they build up causing a metabolic acidosis and spill over into the urine when the concentration is high enough. Identify 5 causes Fluctuations in insulin regime Intercurrent illness Trauma Reduction in carbohydrate intake Dehydration +- severe exercise State 10 clinical features of this clinical state High blood sugar levels Frequent urination (polyuria) and thirst Fatigue and lethargy Dry skin Facial flushing Nausea Vomiting Abdominal pain Fruity odour to breath Rapid, deep breathing (Air hunger) Muscle stiffness or aching Coma The principals of management are:- Prompt administration of insulin (usually on a sliding scale) to reduce the hyperglycaemia and ketonaemia Replacing fluid loss (from polyuria and vomiting) usually by intravenous fluids Restabilising electrolyte imbalances secondary to dehydration, metabolic acidosis and hypokalaemia. Treatment for any underlying cause such as infection. LONG TERM COMPLICATIONS There are 10 steps that the diabetic patient can take to reduce his chances of developing complications. Regular screening of BP and maintain at 140/80 or lower. Regular HbA1c testing. Maintain blood glucose levels between 4-7mmols/L before meals. A