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Since you have limited ability to communicate with your popula- tion buy discount olanzapine 7.5 mg line treatment 3 degree heart block, you will need to have a stable of couriers as well as a distributed network of command centers that you can not only send messages to discount 10 mg olanzapine fast delivery medications medicaid covers, but also receive information on the current hurricane damage and needs of communities for resources generic olanzapine 10 mg online symptoms high blood sugar. Now that people have been injured and killed, you will need more medical person- nel and coroners to recover the bodies to prevent disease and infection from being incurred on your population. The last thing you need now is a pan- demic of bacterial or virus infections to afict the rest of your community that was not directly impacted by the hurricane. How will you coordinate your rescue eforts with your neighboring colony to the north? Tere may be some common resources that could be used by both colonies for rescue and recovery operations. Certain skilled laborers may be available in one colony and not the other that can be sent to the neighboring colony that needs specialized services. The neighboring colony in return may be in a position to send resources to your colony. Stage 3 of the Disaster You are now receiving word that multiple dams have either been broken or are fooding due to the winds and high volume of water that is coming in from the hurricane (U. Department of Commerce, National Oceanic and Atmospheric Administration, 2012; Rufman, 1996). In addition, you are now receiving damage reports that your cornfelds have been laid to waste (U. With the dams breaking you will need to shore up those structures and stop any additional fooding. In addition, you will need to send out inspectors to investigate the status of other dams that have not broken and repair the dams if the situation warrants emergency repair work. Using your communication network, you will need to summon all workers that can possibly work on dam and break- water structures to perform repair work, as well as inspect other structures. In addition, you will now need to communicate to the populations around dams that could break that evacuations should occur for residents in those areas. Your organization has two additional problems to contend with: (1) fnding food for your citizens and (2) fnding engineers and construction workers for the dam projects. If the dams are not repaired or inspected properly, you could even have more agriculture destroyed, more citizens displaced, and possibly more citizens killed if the dams do not hold. However, the dam inspection and construction projects, as well as fnding food for your citizens, should be placed as high-priority problems that need to be resolved. Since the rescue process involves frst responders, the other two issues should not detract personnel from working on resolutions to those issues. Tis situation calls for sending out feelers to surrounding states to see if stockpiles of food may be purchased or donated from other colonial governments. If that approach fails, see how many canned and preserved foods can be gathered up and sent to population centers that will be afected by the food shortage. You are receiving reports that a number of people have been displaced and need both food and shelter (Stone, 2006). You send out riders on horseback to use as couriers for communicating with your various emergency crisis units in the feld, and you attempt to gain the confdence of your citizenry that stability will eventually occur. A major priority at this point in the disaster is to make sure that there is enough temporary housing for all of your displaced citizens. One option is to appeal to neighboring communities to take in dis- placed persons until housing can be provided. You have neighboring colonies that can also be called upon to assist with the recovery of the state after the hurricane. Medical personnel and morticians will be needed to take care of the injured and collect the dead to prevent infection and disease from spread- ing. Tere will still be some ongoing rescue eforts, but at this point in time your resources should shift to more of a recovery nature. Calling up any mili- tary aid would be reasonable at this time to show the citizens that the govern- ment is in control of the situation, and this action would also add additional manpower that would be employed with the recovery efort. The issue of setting up logistics for food, water, and medicine coming from neighboring states would also need to be established to relieve your citizens’ plight. You do not have motorized transport and communication has to occur through couriers that travel either by foot or on Case Studies: Disasters from Natural Causes—Hurricanes ◾ 47 horseback. At this point in the disaster, it would be wise as a leader to make visits to areas where the hurricane has hit and provide confdence to your citizens as well as gain frsthand knowledge of the actual situation. However, even in modern times there is a pos- sibility that electricity could be cut of and refrigeration of food would not be possible. In this situation it is important to get as much cured or preserved food as possible. Having preserved food allows for stockpiles of food to be stored and transported more efectively. Since you have to consider that wag- ons are the best transportation you will have at this point, the food will have to be able to be hauled over long distances in all sorts of climates and still be edible upon delivery. The results will often be based on what resources are available to construct housing (e. Another remedy might be to put up a large amount of tents until more permanent housing can be constructed, but one has to keep in mind that the climate might prove to be too harsh for certain populations, particularly the very old or very young, to tolerate for a great length of time. Key Issues Raised from the Case Study The case study illustrates the challenges of dealing with shelter, supplies, and evacu- ation issues in the absence of modern resources. With no power or modern communications the colonists had to overcome the communication issues by using couriers on foot or on horseback to relay messages. In modern times the infrastructure may exist for more modern communication, but that does not always guarantee it will be working properly during times of crisis. Administrators need to have an alternate plan that will consist of more rudimentary forms of communicating in case modern telecom- munications infrastructure fails. Without having the ability to shore up infrastructure, such as dams, the hur- ricane actually caused more damage than would have occurred naturally. When structures such as dams fail, it can lead to a large amount of fooding that will not only kill or injure people, but also cause damage to other infrastructure, such as bridges, houses, and businesses. Administrators need to be cognizant of the dangers of dams bursting during a hurricane or earthquake and should regularly inspect and upgrade that infrastructure accordingly. In the time of when this crisis occurred, modern communication, transportation, and construction materi- als did not exist, which in many parts of the world may still be the case if a natural disaster occurs. Administrators in underdeveloped parts of the world should take heed of these issues and attempt to reinforce infrastructure as much as possible to weather a natural disaster. Galveston Hurricane, Texas, 1900 Stage 1 of the Disaster You are the city manager of a large coastal city of 42,000 inhabitants (Cline, 2000). You are concerned about the possibility of hurricanes hitting your city and causing widespread death and destruction. You have just witnessed the city of Indianola get hit twice by hurricanes and ultimately abandoned by the resi- dents due to the damage that was inficted upon their community (Texas State Historical Association, 2001). You have some residents that favor building a sea wall to limit the potential damage by a hurricane, but their pleas fall on deaf ears (Cline, 2000). To gain this support, the city manager needs to win over the mayor and the city council to bolster the necessary political support that will be needed to build a seawall.
Unlike bisphos- phonates and denosumab buy olanzapine 7.5mg low cost medicine man gallery, odanacatib does not affect osteoclast survival order olanzapine line treatment effect; rather buy discount olanzapine line symptoms viral meningitis, it only inhibits osteoclast function. Nonspeciﬁc cathepsin inhibitors are associated with scleroderma-like skin thickening and rashes, which have not been reported with odanacatib, as cathep- sin K is bone speciﬁc. Anti-sclerostin antibody (romosozumab) is an effective anabolic agent which promotes new bone formation by facilitating Wnt pathway. It is administered subcutaneously monthly or every 3 months and is associated with minimal adverse events, e. Tyrosine Src kinase plays an important role in osteoclast activation and conse- quent bone resorption. Like odanacatib, it only impairs osteoclast function and does not lead to osteoclast apoptosis. The drug is currently explored for osteosarcoma and in skeletal metastasis, rather than osteoporosis. This occurs because of slow pro- gression of immuno-inﬂammatory destruction of β-cells. They are predis- posed for other autoimmune disorders and may have familial clustering of diabe- tes. The following criteria have been proposed for the diagnosis of fulminant type 1 diabetes • Ketosis or ketoacidosis within a week after onset of hyperglycemic symptoms • Plasma glucose level ≥288 mg/dl and HbA1c<8. Treatment includes intravenous saline and insulin during ketoacidosis followed by basal-bolus insulin after recovery from ketoacidosis. In 16 Type 1 Diabetes Mellitus 367 addition, the infants are exclusively breast-fed till the age of 6 months, which minimizes the exposure to environmental antigens. Therefore, occurrence of diabetes before the age of 6 months suggests the possibility of neonatal diabetes. These patients typically present within ﬁrst few days to weeks of life, and the disease commonly remits by 12 weeks of age. However, 50% of these patients may have a relapse of disease during adolescence or young adult- hood. However, glucotoxicity has been proposed as a possible mechanism for rapid decline in β-cell function, which improves after treatment with insulin. The environmental factors that predispose to type 1 diabetes include viral infections (congenital rubella, coxsackie virus, and mumps), dietary factors (bovine milk and gliadin), and toxins (nitrates). Coxsackie virus speciﬁcally affects β-cells in genetically predisposed individuals, and consequently results in insulitis. This may be partially attributed to increase in personal hygiene (“hygiene hypothesis”) and rising incidence of obesity (“accelerator hypothesis”). Accelerator hypothesis proposes that there is an enhanced immuno- inﬂammatory destruction of β-cells in response to increased insulin resis- tance associated with obesity. Insulin resistance leads to increased β-cell antigen expression mediated through rising glucose and free fatty acids levels, thereby augmenting insulitis. In addition, adipocytokines released from adipocytes act as fuel to the ﬁre in patients with obesity. Therefore, obese children who are genetically predisposed for type 1 diabetes have a faster destruction of β-cells. This combination of type 1 diabetes with insulin resis- tance is also called as “double diabetes. Streptozotocin is administered intraperitoneally at a dose of 50–100 mg/kg, and it causes cell damage by karryor- rhexis, while alloxan leads to free radical-mediated β-cell damage. Normal pancreas weighs about 100–150 g and consists of one million islets that contribute 2% of its weight. Absolute insulin deﬁciency manifest as sarcopenia, ketosis/ keto- acidosis and the need for insulin for glycemic control since diagnosis. If the screening tests are negative, retest- ing should be done periodically at intervals of 1–2 years. The prevalence of autoantibody positivity progressively declines with advancing duration of disease. C-peptide is a 31 amino-acid peptide that connects A and B chains of insulin in the proinsulin molecule. In this scenario, assessment of endogenous β-cell reserve may help in differentiating the two. The advantages of estimation of C-peptide over insulin include its longer half-life (30 min vs. C-peptide should be measured only after optimizing blood glucose proﬁle to avoid the effect of glucotoxicity on β-cells. Can C-peptide measurement replace islet autoimmune markers for dif- ferentiating type 1 from type 2 diabetes? C-peptide is a marker of β-cell function and cannot replace islet autoim- mune markers. The 372 16 Type 1 Diabetes Mellitus limitations with C-peptide estimation include less validated cutoffs for deﬁning β-cell reserve and poor diagnostic value in the presence of renal insufﬁciency. In addition, diabetes- related complications like diabetic kidney disease, gastroparesis, and blind- loop syndrome can also contribute to anemia. A period of early intensive glycemic control in patients with diabetes prevents the development of micro- and macrovascular complications in the long run, despite discontinuation of intensive therapy later on. The long-term beneﬁcial effect of intensive glycemic control early in the course of disease is termed as good “metabolic memory” or “legacy effect. Glucose hypothesis states that chronic and persistent hyperglycemia results in micro- and macrovascular complications and intensive glycemic control pre- vents the onset/delay the progression of these complications. This is because of higher susceptibility to hypoglycemia in children due to unpredictable food intake and physical activ- ity. In normal individuals, the ﬁrst phase of insulin secretion starts immediately after food intake and lasts for 10–15 min and is due to release of preformed insulin granules. This is followed by second phase of insulin secretion which lasts for 90–120 min and is due to biosynthesis of insulin. The ﬁrst phase of insulin secre- tion is responsible for suppression of hepatic glucose output, while the second phase regulates the entry of glucose into insulin-dependent target sites including muscle and adipocytes. On the contrary, regular insulin has onset of action in 30–60 min, exerts its peak effect at 2–4 h and its action lasts for 6–8 h. The delayed onset of action of regular insulin mandates its administration at least 30 min prior to meal, and the delay in peak effect results in early postprandial hyperglycemia. In addition, the prolonged duration of action of regular insulin results in late postprandial hypoglycemia, leading to inter-prandial snacking. Further, regular insulin has marked intra- and interindividual variations in absorption (up to 20–50%), thereby resulting in increased risk of hypo- or hyper- glycemia, even with the same dose. Short-acting insulin analogues have an onset of action within 15 min and exert its peak effect at 1 h, and the action lasts for 3–4 h. Because of its rapid onset of action, it is convenient for the patient to administer insulin immediately before a meal, or sometimes immediately after a meal. This may be especially useful in children, elderly, and in patients with gastroparesis.