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Human Adaptations to Extreme Cold

Human Adaptations to Extreme Cold. Abstract Humans have successfully adapted to environmental stresses, including extreme cold. A review of existing literature examining archaeological data, historical data, and current populations regarding human adaptation to cold stress (average annual temperature of ~ -14°C / 7°F) yields evidence supporting distinctive morphological, physiological and behavioral traits that compensate for the stress. Morphological adaptations can be seen in elongated and narrowed nasal passages (long narrow noses), which help warm and hydrate the air before it passes into the lungs; and a decreased surface area to volume ratio and allowing the individuals to more easily maintain a normal core body temperature. Physiological adaptations include: increased basal metabolic rate, which increases the amount of body heat produced; and a higher prevalence of type 1 diabetes, which may be a genetic adaptation that protects cells from freezing. Additionally behavioral adaptations can be observed in agriculture, awareness of fickle environmental factors, and clothing. Traditional populations in sub-polar regions tend to be hunter foragers; agriculture is limited to what can be cultivated in the short growing season. Some populations demonstrate acute awareness of weather patterns, modifying their behaviors to minimize exposure to dangerous conditions while taking full advantage of more temperate periods. The author finds ample evidence of widely varied human adaptations to extremely cold environments which allow sub-arctic populations to survive more easily in their specific environments. Human Adaptations to Extreme Cold Humans have successfully adapted morphologically, physiologically, and behaviorally to environmental stress, including extreme cold. As a species, humans have survived Ice Ages which brought the intensely cold environment, normal for our polar and sub-polar regions, across much of the planet. To understand the wide variety of adaptations which have proven successful, the author explored existing literature analyzing data from archaeological, historical, and anecdotal sources, as well as from current populations. Because more information involving human populations exists for inhabitants of sub-polar regions than for any other extremely cold environments (except high-altitude locales where oxygen level is a significant contributing factor for adaptation and would complicate conclusions which might be drawn about adaptations to cold stress) the author focused there. ‘Extreme cold’ is defined, in terms of environment, by examining monthly mean temperature charts provided online by the U.S. Navy (Guest, 2000). These data show that monthly mean temperatures at sub-polar locations, both north and south, range from -30°C (-22°F) in January to 5° C ( 41°F) in July, with daily variations from -40°C (-40°F) to 30°C ( 86°F) yielding average annual temperatures ~ -14°C (7°F). Ample evidence exists to support conclusions that morphological, physiological, and behavioral adaptations have occurred in response to the stress of existence in extremely cold environments. Morphological adaptations can be seen in elongated and narrowed nasal passages, broad pelves, and relatively short, stocky bodies. (Kennedy 2007; Hernandez, Fox, Garcia-Moro 1997). “Fueguians and the Eskimos are the human groups with the narrowest and highest nasal apertures, displaying a combination of large nasal height and low nasal breadth values, while groups from equatorial areas have low, wide nasal passages” (Herná, et al. 1997). Both groups lived and/or live in the sub-polar regions (one nearer the southern pole, one nearer the northern). Fueguians inhabited Tierra del Fuego, the southernmost tip of South American after the ice sheets receded, ~ 10,000 to 12,000 BP (before present). Unlike the sub-Arctic environment, which is cold and dry, the climate of Tierra del Fuego is extremely cold, rainy, foggy, and windy. Average temperatures are in line with our definition of ‘extreme cold,’ but in addition the area receives ~3000 mm (118 in) of rain each year and strong, persistent winds that blow off the glaciers, inducing a significant windchill affect. (Herná, et al. 1997, and references therein) took craniometric (measurments of the skull) measurements of 180 skulls from three distinct tribal groups of the area and analyzed them in relation to Howells’ 28 craniometric series in order to increase the statistical significance of the sample. When all the measurements were plotted on a climate map, a strong correlation between increased nasal height combined with narrow breadth and extremely low temperatures is apparent. Researchers postulate that high, narrow nasal openings allow frigid air to be warmed by the mucous membranes lining the nasal cavity to prevent damage to delicate lung tissue, and enhance “the recovery of heat and moisture from expired air.” (Herná, et al. 1997) Another morphological adaptation supported by existing studies is a short, stocky body structure. “Body proportions of humans [and other endothermic (i.e., ”warm-blooded”) species] have long been known to show significant correlations with climatic variables and their proxies. Specifically, two empirically derived ecogeographical rules, those of Bergmann (1847) and Allen (1877), state that within a widespread endothermic species, those in colder regions will tend to weigh more (Bergmann’s rule) and be characterized by shorter appendages (Allen’s rule) than their conspecifics [members of the same species] in warmer climes.” (Holliday and Hilton, 2010 and references therein). They also put forward “colder-climate groups being characterized by broader pelves,” and reference C.B Ruff’s work from the early 1990s. Holliday and Hilton (2010) examine skeletal data from the Point Hope Inuit (another name for Eskimo) of North America. A total of 173 individuals, 127 from the Tigara period (13th to 17th century AD) and 46 from the Ipiutak period (~100 BC to 500 AD) were measured and analyzed relative to other Native North Americans, and samples from Europe, North Africa, Sub-Saharan Africa (from similar periods). Based on results from previous studies referenced, Holliday and Hilton concentrated their effort on measurements which have already been determined to vary with climate, “specifically limb bones from the four major limb segments, femoral head diameter, skeletal trunk height (the summed dorsal body heights of T1-L5 plus sacral ventral length), and bi-iliac breadth [pelvic width].” (Holliday and Hilton, 2010). From the basic measurements, the authors computed seven ratios which are identified as indices for comparison. Results show that African samples provide the lowest indices while circumpolar populations show the highest, with European numbers in the middle. Neither of the groups measured specifically for this study (nor the third Native North American sample) is significantly different from the other, but marked variations exist between these groups and both of the African groups. Interestingly, results do not support the authors’ expectation that the Inuit and Europeans would show a discernible variation using the specific indices studied. However, the bi-iliac relative breadth index (pelvic breadth compared to assumed trunk height) did separate these two groups distinctly. As a counter-point, it is noted that there are other factors which can affect overall stature, such as under-nutrition. In a harsh environment, maintaining sufficient nutritional intake is likely compromised, and so the shorter body may not be simply an adaptation to the extremely cold environment. Popular rhetoric holds that a layer of body fat helps keep humans, and other mammals, warm. In his 2007 American Journal of Human Biology article, “Human cold adaptation: An unfinished agenda” Steegmann does not disagree; he says, “Fat insulates better than muscle per unit of thickness. However, in a fit person, muscle layers are usually much thicker than subcutaneous fat and consequently have higher absolute insulative value.” Studies in the 1950s and 1960s (referenced in Elsner (1963): LeBlanc, 1954; Baker and Daniels, 1956; Daniels, et al, 1961) demonstrated that Caucasians with a thicker layer of body fat, as measured by skinfold, maintained core temperature, skin temperature, and metabolic rate more reliably when exposed to 15° C (59°F) for two hours. However, in a similar study (Elsner, 1963) compared the skinfold thickness of eight hunter-gatherer groups (aborigines of central and northern Australia, Inuit of Canada, Eskimos, Alacaluf Indians of southern Chile, Lapps, Peruvian Indians, and Kalahari bushmen), and cold-acclimatized Norwegian students, with urban Caucasians as a control. Skinfold thickness was measured at ten locations: abdomen, back (subscapular), calf, cheek, chin, iliac crest, knee, pectoral, upper arm,and side. The urban Caucasian control group had higher values across the board, except for the cheek measurement. Of particular interest, Canadian Inuit, and Eskimos had amongst the lowest values; not what was expected from populations that acquire 70-75% of their caloric intake (see above) from animal fat. Additionally he measured the rectal temperature, metabolic rate, and skin temperature of his subjects during an eight-hour sleep period with ambient room temperature of 0° – 5°C (32° – 41°F) during which time they had only one thin blanket to wrap up in. Elsner reports that there was poor correlation between skinfold thickness and the measurements of interest during the overnight study. In support of these findings, from another study, Steegman (2007) reports results which demonstrate that Inuit “traditionally had high muscle mass and high work capacity, but low body fat.” Aside from the subjective observation that the “primitive” groups had “better sleep” than the control group, three sets of reactions emerged from Elsner’s study: 1) Canadian Inuit, Eskimos, and Alacaluf Indians, and cold-acclimatized Norwegian students demonstrated high metabolic rates (measurement technique not defined) and warm extremities; 2) Kalahari bushmen and aborigines from central Australia had stable or falling metabolic rate and cooler skin; and 3) Peruvian Indians and Lapps had low rectal temperatures and higher extremity temperatures. So, while a thicker layer of body fat does not seem to be a human adaptation for survival in extremely cold environments, increased metabolic rate and some protective mechanism to keep extremities warm both appear likely. (Makinen, 2007) Physiological adaptations include: increased basal metabolic rate, high protein/high fat/low carbohydrate nutritional requirements, and some evidence of variations in blood chemistry. (Westerterp-Plantenga 1999; Srivastava, Kumar 1991; Moalem, Storey, Percy, Peros, Perl 2004) “…An inverse relationship between BMR and mean annual temperature has been documented, which holds true even when controlled for differences in body size.” (Snodgrass, et all 2005) In fact, Snodgrass, et al (2005) conducted extensive research among the Yakut population in Siberia (sub-polar Asia) which supports the claim that increased basal metabolic rate is an important human adapation to the stress of an extremely cold environment. With a thorough and well-documented scientific process, participants in the Snodgrass study underwent measurements of core temperature, oxygen consumption, carbon dioxide production, and heart rate in a thermoneutral (23° – 27°C) environment after a 12-hour fast. Results for basal metabolic rate (BMR) were predicted based on three standards drawn from a European population: fat-free mass (FFM), surface area (SA), and body mass. In all three cases, for males and females, the Yakut BMR measured significantly higher than predicted values. The BMR of Yakut men and women were demonstrably elevated over their more southern-dwelling, European counterparts. Another metabolic adaptation might be seen in the increased incidence of Type 1 diabetes mellitus among northern Europeans. Moalem, et al (2004) “Recent animal research has uncovered the importance of the generation of elevated levels of glucose, glycerol and other sugar derivatives as a physiological means for cold adaptation. High concentrations of these substances depress the freezing point of body fluids and prevent the formation of ice crystals in cells through supercooling, thus acting as a cryoprotectant or antifreeze for vital organs as well as in their muscle tissue.” Citing the example of cystic fibrosis conferring immunity to typhoid (salmonella typhi), the authors suggest that elevated blood glucose levels, such as are seen when the body does not produce insulin, may be the result of genetic mutation which gave an evolutionary advantage to inhabitants of cold climates about 14,000 years ago when world-wide temperatures dropped dramatically. Life expectancies then were short, so genetic adaptations that enhanced survival would have favored changes in the short term. Now that our life expectancies have increased to 70 years, we can observe that such changes might have been beneficial then, but currently are causing dangerous health issues within the aging population. Traditional dietary intake of these populations of cold-dwellers depends completely on what is available at any given time. In 2004 Patricia Cochran, a native Inuit Alaskan, wrote on the traditional diet for “Our meat was seal and walrus, marine mammals that live in cold water and have lots of fat. We used seal oil for our cooking and as a dipping sauce for food. We had moose, caribou, and reindeer. We hunted ducks, geese, and little land birds like quail, called ptarmigan. We caught crab and lots of fish-salmon, whitefish, tomcod, pike, and char. Our fish were cooked, dried, smoked, or frozen. We ate frozen raw whitefish, sliced thin. The elders liked stinkfish, fish buried in seal bags or cans in the tundra and left to ferment. And fermented seal flipper, they liked that too.” She reports that in the short summers the villagers would forage for roots, greens, and berries.. “What the diet of the Far North illustrates,” says Harold Draper, a biochemist and expert in Eskimo nutrition, “is that there are no essential foods-only essential nutrients. And humans can get those nutrients from diverse and eye-opening sources.” Inhabitants of extremely cold climates do not live to eat, they eat to live. The traditional Inuit diet, which seems to a Westerner to be sorely lacking in fruits and vegetables, which the U.S. government insists are necessary for wellness, supplies all they need to maintain health in their sub-polar climate. Vitamin C, which is a vital component for healthy connective tissue, is found in raw animal organs, raw kelp, and even muktuk, which is as rich in Vitamin C as orange juice, gram for gram.Fat-soluble vitamins A and D are metabolically mined from cold-water fish and mammal fats and livers. Not surprising, then, that the traditional Inuit diet comprised 90% of its caloric intake from meat and fish, 50-70% of its calories specifically from wild animal fat – fat is the source of not only calories but also necessary nutrients. This traditional Inuit diet based wholly on what food is available from hunting, fishing and forage-harvesting might be a behavioral/cultural adaptation to the climate, while also encompassing metabolic/digestive adaptations. While morphological and physiological adaptations to environment take eons to manifest, some cultural and social adaptations may be apparent on a far shorter time scale. Steegmann (2007, and references therein) speaks about Richard K. Nelson’s comparison of Kutchin natives of east-central Alaska to Eskimos, explaining Nelson’s observation that Kutchin hunters keep moving if they lose their way, afraid if they stop they will sleep and freeze. Eskimo rest as needed and only move to stay warm. He also noted that Eskimo had a complex understanding of weather prediction and were better equipped to plan accordingly and keep themselves safe. “In both cases, Eskimos seem to practice higher survival skills and both behaviors are strongly directed by cultural traditions.” Two very different responses to the same stimuli in similar environments, with potentially diametrically opposed results: survival and death. Another surprising and non-intuitive variation in responses to the extreme cold of sub-polar life can be found in the clothing styles of arctic and some sub-arctic populations. According to Herná, et al. (1997) arctic inhabitants, such as the Inuit, wear clothing designed to protect them from the harsh cold, whereas the three Fuegian tribes they study, who lived at the southern tip of South America, are anecdotally described as “almost naked throughout their lives.” The Fuegian tribes are extinct, so no opportunities to explore their cultural adaptations to their extreme environment. Human adapation to the stress of an extremely cold environment, such as those of sub-polar regions, can be seen in morphological changes, physiological changes, and behavioral/cultural developments. Morphological changes include long, narrow nasal passages, to pre-warm icy air and protect fragile lung tissues and short, stocky body structure, which increases the body mass to surface area ratio, conserving body heat. Physiologically, increased basal metabolic rate is strongly supported as an adaptation, in a contemporary population, to the extremely cold climate of Siberia. An increased incidence of Type 1 diabetes in cold climates is suggested as a favorable mutation during the rapid onset of a mini Ice Age, but more studies would be needed to prove this as a lasting adaptation. Changes in metabolism and digestion in order to extract necessary nutrients from the limited food sources available in a sub-polar climate may be a physiological adaptation, but without studies to demonstrate a change in how the Inuit (or other sub-polar inhabitant) body processes food in order to extract necessary nutrients, it should be categorized as a behavioral/cultural adaptations. They eat to live, utilizing all food sources available. Other behavioral adaptations can be observed in a more precise ‘weather awareness,’ perhaps, and clothing styles. Human Adaptations to Extreme Cold
Share this: Facebook Twitter Reddit LinkedIn WhatsApp Introduction This placement handbook has been prepared to support your learning during your clinical placement for PY3060B Clinical Pharmacy. It also acts as your diary/log book and should be completed and submitted for assessment. Some sections are required to be signed by the pharmacist supervising you and the case presentation/patient medication review presentation will be marked by the pharmacist. The handbook should be read in conjunction with the student handbook previously used during the clinical visits to Lewisham, Royal Marsden and St. George’s Hospital. As well as providing guidance on patient management plans, presentations, etc., it also contains the Standards for Professional Conduct which continue to apply, irrespective of whether the clinical placement was organised by yourself or by the University. Placements will be two week placements in hospital, community or PCT pharmacy. Your placement provider should confirm your start and end date. The first week should be used to collect data for the placement activities. You need to attend every day from 9am – 5pm on the first week of your placement. The next week should be used to complete the handbook, make sure it is signed and retrieve any missing information. The period during which the placements will occur is from Monday 29th March to Friday 16th April. Your placement provider should confirm your start and end date. You should complete the section for each activity. There are 5 activities in all that you have to carry out during the clinical placement. You must not use the same patient and/or activity for more than one record. Each record must refer to a different patient or activity. In addition to recording the information, you should provide evidence of reflective learning. Reflection is an integral part of the case presentation and Patient Management Plan (PMP) process and is included in the proforma. For the other activities there is a reflective learning sheet to complete. This should be familiar to you as it is similar to the record for your PDP and similar to the RPSGB preregistration records. The handbook should be completed; the appropriate sections signed by the supervising pharmacist. The completed patient management plan should be handed by Tuesday 6th April for students who started their placement on Monday 29th March and on Tuesday 13th April for students who started their placement on Tuesday 6th April and on Tuesday 20th April for students who started their placement on Monday 12th April. Other placement activities should be handed in on Friday 9th or Friday 16th April or Friday 23rd April depending on your start date. Case presentations will be assessed On Monday, Wednesday or Friday week beginning 19th, 26th April or 3rd May. You must ensure that all the activities are signed off by your supervisor or other member of staff. The supervisor may wish to make comments and there is a space for these on each worksheet. The reflective learning sheets should be completed and these also require to be signed by a supervisor or member of staff. Failure to complete these will mean that no marks can be obtained for that activity. Spare copies of all forms and worksheets are available on StudySpace. Learning Outcomes This handbook will support you in achieving the following learning outcomes Demonstrate and apply knowledge of the concept and implication of ADRs. Outline the characteristics of some drug-induced disorders and the drugs associated with them. Relate the selection of therapy to treatment guidelines/evidence base, drug properties and the patient Understand the use of commonly used medical abbreviations. (Complements knowledge gained in Professional Practice 5) Use data from commonly requested biochemical and haematological laboratory tests to monitor drug treatment and disease progression. (Complements knowledge gained in Professional Practice 5) Provide appropriate pharmaceutical advice to potential patients to manage some minor conditions encountered in community pharmacy. Provide appropriate pharmaceutical advice to potential patients and healthcare professionals on the management of a number of common disease states. Produce a structured reflective diary of placement experience Practice activities to be completed during the placement Activities to be undertaken in placement Core Community Hospital PCO 1. Prepare a Patient Management Plan (PMP) 3. Public Health activity, such as Provision of smoking cessation advice/products Emergency hormonal contraception Advice on cardiac health Provision of healthy lifestyle advice 3. Patient Medication History 3. Analyse prescribing data and prepare summary report 2. Counsel a patient on how to obtain optimum benefit from their medicines 4. medication use review 4. Discharge Plan 4. Prescription review 5. Presentation of medication use review and recommendations to community pharmacist 5. Case presentation 5. Case presentation 6. Deal with a request for OTC medicines or minor ailment treatment 6. Shadow prescribing visit 1. Patient Management Plan: Page 1 Patient initials: J.W Name of Pharmacy: Sainsbury Pharmacy Name of GP: Dr Khan Sex: M Weight/Height if available:108 kg /1.74m Age:75 Date:9th June 2010 Presenting Complain (PC): Patient had a cold and temperature and he was currently taking Sudafed. He came in the pharmacy because it was not working and wanted to buy another OTC product. He also had muscle weakness and felt dizzy. Relevant Past Medical History (PMH) Diabetes Osteoporosis Allergies:nkda Patient previous prescribed/OTC medication from PMR Indication in this patient How long on it? Patient previous prescribed/OTC medication: Indication in this patient How long on it? 1.Sudafed 2.Gaviscon 3. 4. 5. Nasal decongestants Gastro-oesophageal reflux disease 7 days 6. 7. 8. 9. 10. Patient current prescribed/OTC medication Drug and dosing details 1.Ramipril(10mg) capsules-take one capsule each day 2.Metformin (500mg) tablets-Take one tablet with or after evening meal 3.Aspirin(75mg) Dispersable tablets Take one tablet once each day after food 4.Simvastatin(40mg)tablets-Take one tablet at night with food. 5.Omeprazole (20mg) capsules-Take one capsule each day 6.Alendronic acid (70mg)tablets-Take one tablet each week 7.Cal D3 chewable tablets-take one tablet twice each day Indication Hypertension Type 2 diabetes Prevention of an atherosclerotic event Lowering cholesterol Gastro-oesophageal reflux disease Osteoporosis Osteoporosis Duration Summary of monitoring parameters Measure blood pressure and liver function tests. Measure blood sugar glucose level and HB1ac. Measure cholesterol levels. Patient Management Plan: Page 2 Tests if available e.g. BP, glucose or cholesterol (normal range) Date 9th June 2010 1.Blood pressure (130/85 mmhg ) – 164/83 mmhg 2.Pulse rate (60-80 beats p/min) – 67 beats p/min 3.Total cholesterol (3-5mmol/l) – 8.21mmol/l 4.Cholesterol (HDL)(>1mmol/l) – 0.8 mmol/l 5.Blood glucose (<7mmol/l) -11.2 mmol/l 6. 7. 8. 9. 10. 11. 12. Significance of results outside normal range if available: The blood pressure is very high, cholesterol levels are high especially the total cholesterol levels. The HDL levels are slightly low The glucose levels are out of range and are high. Other considerations (social issues, compliance); The patient is very old and forgets to take his medication regularly and has been advised on the MUR to have a dossete box made for him and delivered which will ensure he takes his medication regularly. Medical Problems 1.Diabetes 2.Hypertension 3.High cholesterol 4.Osteoporosis Pharmaceutical problem list prioritised (max 4 problems) 1.Management of diabetes 2.Management of hypertension 3.Management of high cholesterol 4.Management of osteoporosis Patient management Plan: Page 3 SOAP NOTES (max. 2 pages in font size 11 Arial line spacing 1.5) PHARMACEUTICAL PROBLEM management of diabetes Subjective Patient is overweight Objective Blood sugar levels were measured in the MUR by the pharmacist using the finger prick test. The result of this test was 11.2mmol/l. Patient weighed 108 kg and had a BMI of 30 kg/ m². Blood pressure was high: 164/83. Pulse rate: 68 beats per/minute Analysis The patient is overweight and this is indicated by his BMI of 30kg/m².The blood sugar levels on examination showed to be very high. Normal blood glucose levels range from 4-8mmol/l throughout the day, therefore his blood glucose level of 11.2mmol/l is well out of the normal range. The patient’s high blood sugar levels can lead to micro vascular complications e.g. nephropathy or macro vascular complications e.g. stroke and especially since he has other cardio risk factors e.g. he is obese and has hypertension. NICE Guidelines recommends that if the person is overweight (body mass index greater then 25kg) oral anti-diabetic treatment should be started. If metformin is not tolerated or is contraindicated, then consider starting a sulfonylurea. NICE also recommends rechecking HbA1c within 2-6months to reassess blood glucose control. Currently this patient is on monotherapy on metformin .His blood glucose levels are still very high. If blood glucose control is not being achieved NICE guidelines recommends that a second drug can be added if the person is already taking the optimum dose. If patient is taking metformin one of the following options can be considered: Add a sulfonylurea If the person has an erratic lifestyle add a rapid acting insulin secretagogue(nateglinide or repiglinide) If there is significant risk of hypoglycaemia (or its consequences) with sulfonylurea, or is sulfonylurea is contraindicated add a gliptin or glitazone. The patient has high cholesterol levels and is currently taking simvastatin for this which is also recommended by NICE as 1st line treatment for the management of blood lipid levels in people with type two diabetes. The patient is on a dose of 40mg taken once daily at night. This could be increased to the maximum dose of 80mg since his total cholesterol levels are high. The patient is also on antihypertensive medication and should maintain a blood pressure below 140/80 mmhg since he is diabetic. NICE recommends an ACE inhibitor should be first line treatment here. His blood pressure is currently 164/83mmhg which is above the target blood pressure an according to CKS guidelines if the blood pressure does not meet the target blood pressure referral to a specialist maybe required. Plan The plan is firstly make sure the patient knows the lifestyle interventions he can take to reduce all risks of complications of his diabetes. This patient is obese and has a BMI of 30. He should be encouraged to lose weight and be given appropriate dietary advice, i.e. reduce fat intake, eat more fruits, vegetables and carbohydrates. Since he has a BMI of 30, he may be referred to a dietician for weight loss medication. This weight management advice will help reduce his risk factors for diabetic complications as well as other cardiovascular complications he has a risk of. Currently he is taking metformin to control his blood glucose levels. The dose of Metformin could be increased gradually to the maximum dose of 2g.if this does not control the blood glucose then Sulfonyureas should be added as a combination therapy according to NICE guidelines since his blood glucose levels . He should also be made aware that he can test his blood glucose levels at home using the finger prick test to make sure his blood glucose levels are controlled. Blood pressure should be monitored at least every 1-2 months until it reaches the target blood pressure and to ensure patient does not turn hypotensive. Patient management Plan: Page 3 SOAP NOTES (max. 2 pages in font size 11 Arial line spacing 1.5) PHARMACEUTICAL PROBLEM management of hypertension Subjective NIL Objective On examination blood pressure was 164/83 Pulse :67 beats/min Total cholesterol:8.21 HDL:0.8 Glucose:11.2mmol/l BMI:30kg/m Analysis From examination the patient’s blood pressure has elevated from his previous blood pressure shown on the patient medication record which was 158/84.The patient had a cold and came in for alternative decongestants to Sudafed which he was currently taking for his cold symptoms that he was experiencing. Sudafed should not be taken since he is a patient on anti hypertensive medication. All decongestants should be stopped. Patient should be advised of alternative regimes he can take to combat his cold symptoms such as olbas oil inhaler, vick’s rub and paracetamol to lower his temperature. According to NICE guidelines in hypertensive patients aged over 55 or black the 1st choice for initial therapy should be calcium channel or thiazide diuretics. Step 2 is adding an ACE inhibitor if the initial therapy was a calcium channel blocker or thiazide diurectic.if initial therapy was an ACE inhibitor add a calcium channel blocker or diuretic. Step three in the guidance recommends using combination of three drugs: Use combination of ACE inhibitor, calcium channel blocker and thiazide type diuretics should be used. Step four in the guidance recommends adding an alpha blocker, spironolactone or another diuretic. If the blood pressure remains uncontrolled on adequate doses of four drugs and expert advice has not been obtained this should now be sought. Currently the patient is on the maximum dose of Ramipril which is 10mg for hypertension. His blood pressure is still elevated and step 2 therapy would be essential and if after regular monitoring if the blood pressure has not been lowered step 3 may need to be put into the drug regime. Since the patient is also diabetic his target blood pressure needs to be for a diabetic patient needs to be considered and should be aimed at less than 140/85. Plan The patient needs to moved to step two of NICE guidelines and therefore be on a combination of an ACE inhibitor and calcium channel blocker or thiazide diurectis.If the combination of ACE inhibitor (Ramipril) and a thiazide diuretics(furosemide) is chosen then careful monitoring of his electrolytes, urea and creatine should be done. The patient’s blood pressure should be monitored regularly i.e. – once every four weeks to assess treatment response. Whilst on drug therapy patient needs to be given lifestyle intervention advice to take alongside the drug therapy. The patient needs to be advised to have a low fat and low saturated fat diet which will help reduce his weight since he has a high BMI of 30mg/m, reduce his salt diet intake (less 6g salt per day), increase fruit and vegetable consumption and reduce cardiovascular risk by stopping smoking and increasing oily fish consumption. Dynamic Exercise would also help the patient as part of his lifestyle intervention, although since he is very old this is not ideal for the patient.His glycaemic control should be optimised as he is a diabetic (HBA1c of less than 7%) and regular blood sugar levels should be monitored. 2. Patient Counselling Patient initials: Sex: M / F Age: Location of Counselling (e.g. community pharmacy, counselling room, ward type, out -patient) Current medical problem(s) (if known): Patient’s needs ( other considerations): Current medication (drugs and doses) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Main Counselling points to cover Supervisor’s signature: Student signature: Date 2 Patient Counselling: reflective learning Date Brief summary of the nature of the activity What were you trying to achieve? What happened / what was the outcome? What have you learnt as a result? What do you want / need to learn more about? Tutor/Supervisor Comments Tutor/Supervisor Name Tutor/Supervisor Signature Date 3. Public Health Activity: Patient ID (init) DOB/age: M/F Current problem(s) Relevant past medical history: Current Medication (if known) (Drug, dose, frequency) 1. 2. 3. 4. 5. Activity: Source Patient Pharmacist Referred by GP Other …………….. Reason Describe activity and how the situation was dealt with. Advice/information provided Product supplied or sold Other issues and comments (patient hard of hearing, mobility, who manages medicines at home, etc) Further action if needed and outcome Tutors Comments Signature Date 3. Public Health Activity: reflective learning Date Brief summary of the nature of the activity What were you trying to achieve? What happened / what was the outcome? What have you learnt as a result? What do you want / need to learn more about? Tutor/Supervisor Comments Tutor/Supervisor Name Tutor/Supervisor Signature Date 4. Patient medication use review Page 1 Patient: DoB Conditions/diagnosis MEDICINE (include dosage details) MODE OF ACTION INDICATION (Appropriateness) MONITORING (EFFICACY/SAFETY) PARAMETERS COUNSELLING POINTS 4. Patient medication use review Page 2 Issues and Recommendations Issues Contribution/recommendation Outcome For the attention of… 1. 2. 3. 4. Reflection on Significant Events: References Used: Supervisor’s Comments

CRJS 405 AIU Research Methods and Statistics for Criminal Justice Discussion

CRJS 405 AIU Research Methods and Statistics for Criminal Justice Discussion.

You are discussing qualitative and quantitative research that has been used to improve public safety. Select your favorite 4 examples of qualitative and quantitative research. Using this list, draft an argumentative essay that convinces the reader why both qualitative and quantitative research are important to public safety. Consider the following questions: What are the limitations of qualitative and quantitative research? What are potential issues in only using qualitative or quantitative research? What value comes from undertaking qualitative and quantitative research?The specific steps are as follows:Reviewing the unit Discussion Board, find your favorite 4 examples of research using both qualitative and quantitative research. Construct a 4-page argumentative essay convincing your reader of the value and importance of using both qualitative and quantitative research. Address each of the following questions: What are the limitations of qualitative and quantitative research? What are potential issues in only using qualitative or quantitative research? What value comes from undertaking both qualitative and quantitative research?Use no fewer than 6 scholarly resources.
CRJS 405 AIU Research Methods and Statistics for Criminal Justice Discussion

Montana State University Billings Changing Consumer Behaviors Essay

online dissertation writing Montana State University Billings Changing Consumer Behaviors Essay.

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This week you were assigned to read Chapter 7 in the text. There was also a link ( you had listed as one to watch which depicted an example of a Public Service Announcement (PSA) in Hong Kong by Volkswagon. The video depicts an example of an attempt to change consumer attitudes about texting and driving. This week I want you to find a video clip, print advertisement, or other form of example of an attempt to change consumer attitudes towards a product. A successful discussion post will contain the following:1. A link to the video clip, a pasted version of the print advertisement, or some other method for each of us to view the selected example you will be discussing.2. You must give a short description of the product, manufacturer, and date of publication for the example.3. 7-5 (Chapter 7 of the text, pp. 138-144 in edition 7/ Chapter 7 pp. 140-146 in edition 8) describes Attitude Change Theories and Persuasion. Which approach is your example using? (A successful answer will include the approach, a short description of it, and then supporting information about HOW it is being used in your example).4. How effective (in your opinion) is this attempt to change consumer attitudes of the product? (Do not just tell me – very effective. A successful answer will include supporting information about why you believe it is or is not an effective attempt). Your response needs to be a minimum of 350 words, use proper APA format, and address all of the above components.
Montana State University Billings Changing Consumer Behaviors Essay

BIM-Based 3D Reconstruction Technology

BIM-Based 3D Reconstruction Technology. Optimization Model of BIM-based three-dimensional reconstruction technology and engineering model of visual perception Keywords: Three-dimensional reconstruction, visual perceptual model, engineering optimization, modeling, analysis. Abstract.Vision-based reconstruction is still there is a big limitation. Through its research-based approach introduces the primary visual three-dimensional reconstruction techniques, advantages and disadvantages of various methods were compared, it is desirable in this area can have a more comprehensive grasp, to further clarify the direction of future research. In order to improve the efficiency of the design and construction of bridge engineering, building information modeling (BIM) is introduced into the bridge project in the past. By analyzing the characteristics of bridge design and construction and the problems proposed bridge design and construction BIM-based optimization solutions, including preliminary design optimization, optimization of construction design, construction process optimization, optimization of the construction schedule and construction management optimization, combined with practical engineering project the applicability and effect analysis. Case application shows, BIM Bridge Project is applicable, can provide effective support for the bridge design and construction, thereby reducing rework and improve efficiency. The study may be large or complex bridge engineering BIM improve the efficiency and effectiveness of the design and construction of reference. Introduction The relevant information and data building information model is based on building projects as the basis for the model, building model were established by the real information of the digital information simulation building has, it has the visibility, coordination, simulated sex, optimality and showing of five characteristics. The BIM technology in the field of bridge engineering construction is currently in the early stages, preliminary exploration in the design, construction, and post-operation maintenance and repair of the entire life cycle of how to use BIM technology to improve design efficiency, improved design quality, strengthen the construction organization and post operations management, specific method and the application of BIM technology can bring benefits, hoping to BIM in bridge engineering to develop ideas. In recent years, domestic construction projects in the field of non-BIM is none other than the hottest technology in the construction industry has achieved good results after the application, the state began to vigorously promote the railway, highway, water conservancy and hydropower industry application of BIM technology in fields such as engineering, and bridge engineering in the construction field and a large proportion, especially high-speed railway, mountain railway, roads, bridges, often accounting for a larger significance in bridge engineering applications BIM technology on the entire major project, the paper will design, three stages of construction, operation and maintenance of the latter part of the project life cycle are the practical application of research needs and the effect of BIM technology. In recent years, should the needs of economic development, large, extra large bridge project more and more, such as China, Hangzhou Bay Bridge, the Hong Kong-Zhuhai-Macao Bridge, which bridge design and construction of a higher requirement. Bridge construction project not only involves complex geographical environment, and involves a number of complex projects, the most typical is the Steel Bridge. Currently, the design of large bridge projects usually rely on the traditional two-dimensional drawings and graphs to analyze the design by closing existing in conflict; construction planning is largely dependent on the experience of project managers to develop and implement, and is also a two-dimensional drawings to show. However, since the bridge project their own characteristics, its design complexity, component many rely solely on the traditional two-dimensional drawings difficult to detect in advance or found conflicts existing in the design; these design problems usually can be found in the construction phase, thus affecting the construction schedule and cost, will also affect construction safety. At the same time, in order to resolve the problem of engineering design and construction, we had to deploy more staff, which is also a significant increase in management costs. Therefore, to ensure the feasibility of the bridge may be constructed of engineering design and construction programs for efficient implementation of the bridge project is very important. Preliminary design stage is divided into two stages of design and post-design, including pre-design project approval, feasibility studies and scheme comparison and other parts, three-dimensional solid model of the bridge by using parametric modeling tools can be easily established according to the actual need to adjust the size, and the actual effect of the bridge into the real-time dynamic display, to achieve WYSIWYG, can intuitively design concept, design effects directly model the three-dimensional visualization of the project as a carrier to deliver policy-makers, which greatly facilitate the adjustment of the design, be revised in accordance with amendments and rendering, and cost control by adding information to keep abreast of changes after the investment increases and decreases, so that the bridge-bridge quickly determine preliminary program is very convenient and efficient. Figure 1 is a railway bridge stayed Bridge main bridge model, we need to establish a special bridge structure according to the characteristics of the family library for complex bridge structure using three-dimensional expression of BIM model than the traditional two-dimensional drawings clearer and easier to understand. The Proposed Methodology Three-dimensional modeling techniques.The use of modeling software for three-dimensional modeling is commonly used method, but modeling the need to spend a lot of manpower and material resources are often prohibitive, reconstruction effect is often unsatisfactory. Vision-based reconstruction technique to solve this problem and provides a new way of thinking. Three-dimensional vision-based three-dimensional reconstruction technology, which uses computer vision methods of three-dimensional model reconstruction of the object, is the use of a digital camera as the image sensor, the integrated use of image processing, visual computing technologies such as non-contact dimensional measurement, obtaining object using a computer program information. The advantage is that the shape of the object is not restricted to rebuild faster, can achieve automatic or semi-automatic modeling, three-dimensional reconstruction is an important direction of development, can be widely used, including autonomous mobile robot navigation systems, remote sensing and aerospace, industrial fields of automation systems, etc., the economic benefits generated by this technology is very impressive. As an important branch of computer vision technology, vision-based three-dimensional reconstruction of Marr visual theoretical framework is based on the formation of a variety of theoretical approaches. For example, according to the number of cameras can be divided into monocular vision method, binocular vision method, three monocular vision or monocular vision method; according to different principles, vision-based method can be divided into regions, feature-based visual method , model-based and rule-based visual methods; according to the obtained data the way, can be divided into active and passive visual method visual method. Figure.1 Three dimensional reconstruction technique According to research at home and abroad in recent years, were selected based on visual presentation of three-dimensional reconstruction of research and practical application of several methods and more comparative analysis, pointed out the main challenges for the future and the future direction of development. Depending on the number of cameras to use, this article will be divided into three-dimensional reconstruction method based on the visual method of monocular vision, binocular vision trinocular vision method and three methods were introduced, focusing on the monocular vision method. Monocular vision method.Monocular vision method is the use of a camera for three-dimensional reconstruction method. Images used can be a single point of view of single or multiple images can also be a multi-view multiple images. The former is mainly characterized by a two-dimensional image depth information deduced, these features include two-dimensional shading, texture, focus, contour, etc., it is also referred to as X shape recovery method. This simple device structure class methods, the use of single or small number of several images can be reconstructed three-dimensional object model; less than that normally required conditions more idealistic, practical application is not very satisfactory, the effects of reconstruction in general. The latter by matching different images of the same feature points matching using these coordinates in space constraint obtaining information in order to achieve a three-dimensional reconstruction. This method can be implemented in the reconstruction process of camera calibration, to meet the needs of large-scale reconstruction of three-dimensional scene, and in the case of resource-rich image reconstruction is better; the downside is that a greater amount of computing, a long time to rebuild. The following describes several major monocular vision method. Shading method.Shading method, that the brightness of the shape recovery method (SFS). This approach by analyzing image brightness information, using reflected light model, restore the normal to the surface of three-dimensional reconstruction information. Horn in 1970 first proposed the concept SFS methods, and gives a non-linear relationship between the two-dimensional image showing the brightness of each pixel in the corresponding three-dimensional point of law to the reflectance of light and the direction of Partial Differential Equations , the brightness of the equation. However, this method is a SFS under-constrained problem and needs to solve other constraints. Therefore, the traditional method of SFS also based on three assumptions. The main advantage of the brightness of the method is that it can recover from a single image in a more precise three-dimensional model can be applied in addition to mirror the object almost all types of objects. However, the brightness of the reconstruction of relying solely on mathematical calculations, results are poor, but because of the lighting conditions more stringent requirements, the need to know the precise position and orientation of the light source and other information, so that the brightness of the method is difficult to apply in the case of an outdoor scene lighting and other complex three-dimensional reconstruction on. Photometric stereo.Although the shading method to support the reconstruction of three-dimensional model from a single image, but less information is available in a single image, the actual reconstruction of the general effect. So Woodham of SFS method is proposed to improve the photometric stereo. Photometric stereo by a plurality of non-collinear light source to obtain multiple images of the object, and then a different image brightness simultaneous equations, solving the surface normal direction of the object, and ultimately restore the shape of the object. Technically, the use of two light sources can be obtained method object to the information, but the use of multiple sources of data redundancy can be resolved by the shadows and specular reflections caused by such factors can not solve the problem, better robustness, reconstruction effect It can be improved, so the current method basically using a plurality of (four to six) three-dimensional reconstruction of the light source. Photometric stereo advantages and brightness of the same law, the use of multiple images at the same time avoids the problems of ill shading method, and the use of multiple light sources also increased constraints, to improve the accuracy and robustness of the method; it the disadvantage is difficult to apply a mirror surface object and three-dimensional reconstruction of outdoor scenes and objects. Texture law.Humans can surface texture by projection on the retina perceive three-dimensional shape of the object, so the visual image information gradient texture can be used as information for Shape and depth cues. Based on this theory, the analysis can be repeated by surface texture unit image size, the shape, the recovery of the normal object, the depth information to obtain three-dimensional geometric model of the object, i.e., texture profile method for recovery. Texture is the basic theory of law: For a smooth surface and having a repeating texture units covering the object of which, when projected on the two-dimensional image, texture unit on which will be deformed, this deformation is divided into projection distortion (projective distortion ) and perspective shrinkage. Projection distortion so the farther away from the image plane texture unit looks smaller foreshortening distortion and image plane makes an angle greater texture unit looks shorter. Because these two variants can be measured from the image, so it can be analyzed after deformation texture units, reverse strike the surface normal and depth of information, three-dimensional reconstruction. Profile method. This method of contour images of objects through a plurality of angles to give a three-dimensional model of the object. Profile method can be divided based on voxel cone prime three methods based on visual and shell. Figure.2 Visual perception model Conclusion Reconstruction of 3D Vision technology is still in the exploratory stage, the practical application of the various methods is still some distance away from a variety of application needs to be urgently met. Therefore, in the future for a long period of time, we also need to do more intensive research in this field. This study shows that, BIM can provide effective support for the bridge design and construction. This study was expected to provide reference for increasing large, complex bridge design and construction efficiency and effectiveness, as well as assist in the promotion and application of BIM in the field of civil engineering. I believe that with the continuous promotion of theory and technology of BIM, BIM applications in civil engineering will become increasingly widespread, so as to improve their quality, efficiency and management level. Safety-critical structural bridge engineering, maintenance and repair of the late, operations management, file management can take advantage of powerful information technology BIM, visualization capabilities to achieve. BIM-Based 3D Reconstruction Technology

UTA Information Technology Importance in Strategic Planning Blockchain Essay

UTA Information Technology Importance in Strategic Planning Blockchain Essay.

Industry experts believe blockchain is a technology that has the potential to affect the business of most IT professionals in the next five years. Pick an industry you feel will be most affected by blockchain and how blockchain may be used in that industry. As an IT manager, how would you embrace blockchain? For instance, how would training occur for your team, what strategies might you use, what security methods may you recommend be used?Your paper should meet the following requirements:• Be approximately four to six pages in length, not including the required cover page and reference page.• Follow APA7 guidelines. Your paper should include an introduction, a body with fully developed content, and a conclusion.• Support your answers with the readings from the course and at least two scholarly journal articles to support your positions, claims, and observations, in addition to your textbook• Be clearly and well-written, concise, and logical, using excellent grammar and style techniques.
UTA Information Technology Importance in Strategic Planning Blockchain Essay

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