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Stetson University MSDS Acetone Questions

Stetson University MSDS Acetone Questions.

Hello I have the MSDS attached and this is what my instructor gave me: On a separate sheet of paper, answer the following questions about your specified chemical compound and attach a print copy of the MSDS that you downloaded and utilized to answer these questions, turning in these items to your lab instructor as directed:The CAS registry number and any hazard(s) identification(s) for the substance.List any first-aid measures associated with the substance, considering possible skin contact, eye contact, inhalation, and ingestion?The NFPA rating, and fire fighting measures that need to be considered.What toxicological information is associated with this chemical, if any?List any LD50, PEL, TLV, and/or STEL exposure limit information that may be listed for this chemical.
Stetson University MSDS Acetone Questions

Introduction The author of this assignment will critically appraise a qualitative research report in the Nursing Standard titled Care of older people with dementia in an acute hospital setting.(Fiona Cowell, 2009) (appendix 1). He will use the Polit and Beck (2010) and Roe (1998) framework to help him critique this article. The article was chosen mainly on a personal reasons that as a third year student nurse the author has witnessed how healthcare professional act differently towards patients with dementia and how there is a need for education to improve Health Care professionals skills in dealing with dementia patients. Also according to the Alzheimer’s society (2010) there are approximately 750,000 people with dementia in the UK. The reason for nursing research is to generate knowledge about nursing education, nursing administration, health care services, characteristic of nurses and nursing roles, in which the finding from these studies indirectly affect nursing practice and thus add to nursing body of knowledge. (Understanding nursing research, by Nancy burns and susan.k.grove, 2006). Introduction to the study According to Gerrish and Lacey (2006) the introduction must convince the reader that the proposed study is important and it should identify how the study will add to previous work and build on theory. For the purpose of this research paper Cowell (2009) has decided to write the introduction separate from the main abstract. Cowell clearly explains why the study needs to be investigated within the introduction and convinces the reader that the best way to investigate this research would be to use a qualitative approach, to address this gap in knowledge. Title According to Parahoo (2006) titles that are too long or short can be confusing or misleading. The title should suggest the research problem/purpose of the study. The title in Cowell’s (2009) study is unambiguous, concise, and highlights with clarity the content of the research study. Literature Review A Literature review is to give an objective account of what has been previously been written on a giving topic (Moule and Goodman, 2009). In this research the literature review provided a list of data bases that where used to search for articles papers on dementia and keywords that where used within the search. She also included the period 1980-2004 that she used within her literature review. The articles investigated a range of different subjects however there was limited evidence that these had achieved a demonstrable change in practice due to study limitations and the sample size. The literature review does comment on only a few research articles out of forty seven she found. This may be due to study limitation and one in particular, which was relevant to Cowells study was that none of the patients where actually diagnosed with dementia. Holloway and Wheeler (2010) state that normally in qualitative literature overview the discussion of literature tends to be more limited than in other types of research. The articles that the researches choose to comment on helps to convince the reader that views of nurses on dementia care are limited and that care of dementia patient in acute hospital needed to be addressed. Overall the literature review provides detailed references, keywords and information on how she went about her search, but the study fails to provide recent research material in conjunction with the study title. Moule and Goodman (2006) advise researchers to use up to date studies, that is, certainly not more than ten years old and preferable not more than five years old. The reason why Cowell hasn’t used any up to date studies may be because she might not want readers to be influenced by any previous material and that dementia has become a focus of political agendas, which enables the researcher to identify gaps that can be addressed. Methodology Cowell has used a qualitative approach to this study and has decided to use naturalistic paradigm. Naturalistic researchers tend to look in detail at a specific group of people or a particular situation (Walsh and Wigens, 2003). This approach tries to gain an awareness and appreciation of how particular individuals or groups of people view and experience the world (Moule and Goodmand, 2009). Qualitative research is a form of social inquiry that focuses on the way people make sense of their experiences and the world in which they live (Holloway and wheeler, 2010). Where quantitative research seeks to test a hypothesis or answer research questions based on a framework (LoBlondo-Wood and Haber, 2006). The researcher tells the reader in the abstract that she will use an ethnographic approach. Ethnography means a “portrait of people” and involves writing about people and culture (Moule and Goodman, 2009). These approaches use observational and interview data collection methods, which is what the researcher has used within this research article. The aim of ethnographers is to learn from (rather than to study) members of a culture group to understand their world view as they perceive and live it and social norms of a particular group, such as nurses (Polit and Beck, 2010). Overall the researcher has used the best approach to find out the experiences of patients and nurses in relation to care delivered to, and received by, older with dementia. Data Sampling Data was collected during 2005- 2006 from 3 special older people wards. The researcher mentions that ethnographic observations and interviews where used and that a total of 125 hours of observation were completed in two five-hour blocks between 7am-8pm. Field notes where transcribed and eighteen interviews were audio taped. No rationale was given for how the decision about the type of interviews that were going to be used. According to Moule and Goodman, (2009) it should have been clearly presented and justified. How the data was collected in relation to the methodology used was ok but limitations to the study for example small sample size, using patient that had server dementia who may have had cognitive impairment. Which overall might have had influences on the results. Gerrish and Lacey (2010) say that sample size is not an intrinsic feature of the analysis in qualitative research. Data Analysis Data was transcribed and verbatim as soon as possible following the data collection. This method also has implications in that the researcher may have to transcribe the interview (“write out what is said”) (Moule and Goodman, 2009). Ethical Considerations Nurse researchers have a professional responsibility to design research that uphold sound ethical principles and protect human rights (Speziale and Carpenter, 2007). I.e. informed consent, gaining access, confidentiality, anonymity and avoid harm. Cowell has appeared too adhered to the guidelines and adequately safeguarded the rights of the participants due to the incorporation of these 4 principles into her research design. Ethical approval was also gained from the local NHS research ethics committee and the NHS Trust involved within the study. All participants gave verbal consent before each period. Results The researcher used two subs headings within the findings/results she listed them as Patient experience of care and Nursing Staff experiences of care delivery. Within the findings section the researcher used some direct quotes from both the patient and nursing staff, which the reader found they where biased and not very reliable. Only because a small sample number of patients where involved with-in the research and all had server dementia which could have been an influence. According to the Alzheimer’s society (2010) Memory loss is likely to be very severe in the later stages of dementia. So why did the researcher not included patients who where newly diagnosed or only had mild dementia that where able to communicate more and probably expressed the feelings better. The strengths of the results was that all the patients where diagnosed with dementia before they where admitted to the hospital and Mini-mental examination where carried out, which results ranged from 0-7 that indicated server dementia. The researcher also never comments on any organisation or environmental factors that could of influenced the results or have an impact on the patient’s feelings/experiences. Discussion The discussion is clearly separate from the actual findings which make it much easier for the reader to read and understand her work. The findings are well discussed within this article and the researcher relates back to her literature review and back ground information. The major findings within the article where interpreted, discussed and backed up by references. The researcher did discuss that little is known about acute hospital care from the perspective of people with dementia. She never mentioned the different types of dementia the patient had been diagnosed with and if any cognitive skills were impaired. Normans (2003) process was used within this article, which is a process that encourages the researcher to take account of his or her influence on the study. The researcher does state to the reader that this could have influenced the data results. LoBlondo-Wood and Haber (2006) suggest that the research may influence the participants if the researcher observers the participants to collect data. The researcher decided to use two different methods of collecting data. This is known as triangulation collection. Triangulation is thought to improve the validity of a study, by drawing on multiple reference points to address research questions (Moule and Goodman, 2009). Researchers using triangulation in data collection are hoping to overcome potential biases of using a single data collection method. Brewer and Hunter, 1989 says that no one method is perfect, though using a combination of methods can, it is argued, limit the potential deficits and biases of one-particular method. So with the researcher using both the interviews and observations she has enhanced the reliability, validity and trustworthiness of this research study and its overall quality. No recommendations of further research were discussed within this article. Study Limitations The researcher does mention study limitations in a separate column in which she comments that the study was on a small scale and conducted in one acute hospital. Therefore the findings are not generalised, but may be transferable. As the work has been interpreted by the researcher she does say openly that the article is biased. The researcher also says she never returned to the other participants to check data, as she believed it would be a burden to them, and may have limited valve. (REF about going back to participants) She failed to mention the Hawthorne effect could have affected the participant’s behaviour or performance, which could have impacted subsequently on the dependant variable (Moule and Goodman, 2009). Relevance of the study to practice The issues that Cowell (2009) identifies have also been seen over the years on clinical placements that prove Health Care Professionals need further education on dementia care. This will help patients in the future receive more patient focused care/individual care and not personalised dementia care. The author doesn’t think it would be hard to change practice due to the evidence within this study that nursing staff have a lack of knowledge and education in delivering nursing care to dementia patients. With most staff wanting to gain a more understanding in dealing with dementia patients the only factor that may be challenging would be resources, cost and time management on the ward area for staff to do the training. Also by having Nursing journals available in ward areas would help staff attitudes for further training and using evidenced base research in practice. There are other factors like staffing issues on the wards that are affecting patient care, which with the right staffing would improve patient focused care but further research would be needed to prove this. The comments within Cowdells (2009) article and experience on clinical placement have made the author realise he acts as an advocate for dementia patients and that in the future he will make sure everything is done in the patient’s best interest, instead of the nursing staff convenience. The use of evidence based studies is the best way to improve quality of care and improve patient experiences is essential (ref). Evaluation Cowell (2009) study has been subjected to critique using the Polit and Beck (2010) and Roe (1998) framework, which has helped to gain a more understanding of dementia care. Her article is presented well and flows that makes it easy to read and understand. Cowdell (2009) chose a good method and approach but there where flaws within her data sampling, which was addressed within report. This could have posed a threat to validity and reliability. By critiquing this article it has helped the author to increase his knowledge on reading research articles, understanding the terminology and appraising nursing research. It has also made the author more aware of how dementia patients feel in acute hospital setting and how he can, as a future staff nurse can make a change on how care is delivered to dementia patients.
One of the things that make human life intriguing and to some extent captivating is the diversity and variation exhibited by people as a result of their differing cultures, jobs, personalities and physical appearance. The American society in particular exhibits this great diversity since people of differing races and cultures have made the country their home. Moreover, people are constantly immigrating into the United States therefore increasing the diversity of the country. At times there exists misinformation about the new immigrants which results in over generalize and people judging the newcomers based on narrow minded and often misguided preconceptions that they have about them. Being an American of Chinese origin, I view myself as an open minded and accommodative person who respects people of all cultures. As a teacher, I get the opportunity to interact with new immigrant students who are at times going through cultural conflicts as a result of the change in their environment. One such experience was with a Korean immigrant named Chung. My interaction with him resulted in a deeper appreciation of the difficulties that new immigrants experience as well as in my helping Chung to best cope in class and in the community. As a child, Chung had great aspirations in life and his parents looked on with pride at the young boy whom they knew would grow into a great man one day. He attended school from an early age and showed keen interest in the various lessons that he was taught. Even as young Chung undertook the physically exerting martial arts training that were mandatory for young people in Korea, he appreciated each moment since he knew that this training would build in him great discipline that would be useful in his future dealings with the world. The role of family in Chung’s life was very important and from an early age, he was taught to value his family ties. This resulted in the formation of an identity as an individual that was closely linked to that of his family. The most important people in Chung’s life were his parents and siblings and everybody else was secondary. However, this familiar environment was about to change following the decision by Chung’s parents to immigrate to the United States of America. Chung’s father who was also the head of the family viewed the US as the land of opportunities where one could be given a chance to achieve great exploits. Chung’s father therefore viewed this move as a good opportunity for himself and his children to make a better future for themselves. Chung was excited about the new possibilities and he was anxious to experience for himself this great new land that he had heard about from so many of his friends. In preparation for this great move, Chung practiced to communicate in English, a language that had been until then foreign to him. His parents emphasized that he would have to master this language in order to enable him to communicate with the people he was going to meet in the new country. Get your 100% original paper on any topic done in as little as 3 hours Learn More On arrival at the United States at the age of 15, Chung was struck by the great cultural difference that existed between his new country and his motherland Korea. For starters, there as a language barrier and his lack of a deep knowledge of English made it hard for him to relate with the other people. In addition to this, America seemed to him to be made up of people of differing colors, cultures and religion. This was new to him since he was used to a homogenous population back in the Korean Republic where almost everyone shared a common ethic, language and historical background. While Chung viewed this as a setback since it was different to his homogenous population that he was used to back in the Korean Republic, I as his teacher showed him that this was indeed a favorable thing to him. Since the US was a land of many cultures, I demonstrated to Chung that he could easily fit in since the American people appreciated diversity and would therefore be least likely to single him out for discrimination. School was the place where Chung got to receive his first impression of what life in America was like. As a new immigrant, Chung was the only member of his class who was of Korean origin. This would have been easy for him to handle had it not being compounded by the many lack of familiarity with most of the activities. For example, the meals offered at the cafeteria were different to the ones that Chung was used to and the other students did not invite Chung to take his meals from their table. This lack of hospitality was in contrast to his motherland whereby strangers were made to feel at ease by being given guidance until they became familiar with their new environment. While becoming accustomed to the new environment was something that Chung would have to do on his own, I as his teacher could help make the process simpler for him. From my personal experiences, I had over the years noted that immigrant students tend to be more sympathetic to the plight of new immigrants since they understand their situation best. As a teacher, I could therefore introduce Chung to older immigrant students who would help familiarize Chung with school life therefore help make the blending process easier for Chung. One of Chung’s most priced possessions was his Kimchi. This was a meticulously carved walking stick that had the Korean national colors painted on one side and the carved image of an old man on the other side. Chung explained to me that he had inherited this artifact from his grandfather and that it had been passed down through generations in his family. We will write a custom Essay on Helping Chung Overcome Cultural Differences specifically for you! Get your first paper with 15% OFF Learn More In addition to the Kimchi’s historical significance, Chung also revealed to me that the artifact was a symbol of his beliefs in ancestral powers. Given the historical and religious significance of this artifact, I now understood why Chung valued this object and held it in near reverence. It struck me that without knowledge of the history of the Kimchi, I would not have appreciated its significance to Chung and would have stereotyped him for it. This is what had been happening in his school whereby other students had been teasing him as a result of his alleged attachment to such items. While the prejudices that Chung felt only resulted in verbal attacks, they can deteriorate further into levels such as physical attacks or even discriminatory behavior if they are not dealt with. Using my newly acquired knowledge, I as a tutor could encourage the students to share their cultures and have them bring family heirlooms to class. By doing this, the students would learn to appreciate each others diversity therefore resulting in more cohesion in class. One of the issues that greatly troubled Chung was his lack of fluency in English. Having identified the language barrier as one of the most significant one in his relation to the society, Chung’s parents made efforts to improve on Chung’s language skills. However, Chung was disheartened by the school environment which he regarded as hostile. This was an issue that I could relate with since I am a native Chinese who came to the US at the age of 15. In my experience the best way to master a new language is to practice it often. As such, I encouraged Chung to communicate with me and with his parents at home in English despite his lack of fluency. There also existed many beginner books and audio language tutorial material in the library. By giving Chung access to this material, he would improve his language skills. His ability to communicate fluently in English would undoubtedly enable him to obtain better grades in school. As a result of unfriendliness towards him at school, Chung had forfeited his opportunity for fulfilling his educational goals by dropping out of school. As a teacher, I could tell that Chung did not give up on school as a result of his lack of interest in learning but rather because he did not have any friends. It was therefore possible that gaining friends would rekindle Chung’s interest in school and give him an opportunity to fulfill his educational goals and have a bright future. I therefore decided to introduce Chung to various activities which would give him an opportunity to meet and socialize with other students of his age. Sporting activities like basketball and skating provided the best grounds to fulfill this. Not sure if you can write a paper on Helping Chung Overcome Cultural Differences by yourself? We can help you for only $16.05 $11/page Learn More I therefore introduced Chung to basketball and he showed a flair for sporting activities as a result of his physically disciplined background. As he played, Chung interacted with other students and soon he had many friends who were willing to introduce him to other activities that enabled him to assimilate to the American culture which had once been alien to him. From his Korean background, Chung had differing cultural practices to those of the people in America. One of the more significant ones was the Lunar New Year (Seol-nal) which was regarded as a very important celebration in his native Korea Republic. At the time of celebration, the families would gather around in their hometowns and traditional food would be prepared for all to enjoy. Chung lamented that his American peers did not share this cultural background with him. With time I realized that while on the surface it looked like Chung’s practices were alien to American ones, a closer look revealed that Americans also have such celebrations. For example, the Thanksgiving Festivities were very similar to Chung’s Seol-nal since they involved family, friends and food being eaten in communion. As an educator, I therefore embarked on showcasing these similarities to Chung’s classmates who showed a greater appreciation for Chung’s practices since they saw the parallels with their own practice. This appreciation of the celebrations resulted in greater respect and appreciation for Chung’s culture. People often engage in stereotyping others mostly as a result of their ignorance. By enlightening such people of the practice and culture of others, they learn how to appreciate them and therefore dispense with their stereotypical views leading to better relations being forged. From my experiences with people of differing cultures, I have learnt that it is only by taking a closer look and actually interacting with the other person that stereotypical and racist perceptions can disappear. This is the case with Chung since the more the people surrounding him understood his practices and culture, the more they were willing to interact with him positively and avoid racist tendencies towards him.

Letter to editor/Representative/Public official regarding water mangement/regulation (1pg)

Letter to editor/Representative/Public official regarding water mangement/regulation (1pg). I don’t know how to handle this Sociology question and need guidance.

ADDRESSEE: clearly identified; addressed accordingly; appropriate titles used; appropriate content for intended audience
CONTENT: clearly articulated argument; utilized personal anecdote(s) and/data and scholarly evidence/references to develop and/or support the argument presented
CLOSING/SPECIFIC REQUEST: strong closing and/or specific and appropriate request made of intended audience
Letter to editor/Representative/Public official regarding water mangement/regulation (1pg)


professional essay writers English. Paper details For this assignment you are asked to write an essay that explains and charts what you have studied over the semester. It can help to view this as a discussion of your experience as a writer in the class. You may use the questions and topics in the Addendum to help as you develop your content. I have also provided vocabulary words and you may add any additional that you wish to include and believe will be helpful. Note: Like other skill-based tasks, writing can always be improved. Overarching questions might be: What are strengths do I have as a writer? How might I improve? What are my challenges? Essays should be uploaded to Turnitin by the start of class on the day of your Final. Format: MLA Style Single-spaced, Times New Roman, 10 point. 750-1200 wordsEnglish

IWU Ethical Considerations in Healthcare Organizations Discussion

IWU Ethical Considerations in Healthcare Organizations Discussion.

Discussion Post Topic: Social, Legal, and Ethical ConsiderationsGlobal communication, social networking, artificial intelligence, sophisticated healthcare technology, electronic storage of information, and numerous decision-support tools present a plethora of social, legal, and ethical considerations for healthcare providers. The assigned readings will help you to explore recommended approaches and initiatives to maintain the integrity, safety, and security of healthcare information when computer technology is used.Upon successful completion of this discussion, you will be able to:Examine legal, social, and ethical issues related to computer technology in healthcare.ResourcesTextbook: Applied Clinical Informatics for Nurses (Link to e-book included with Login information will be provided)File: A Nurse’s Guide to the Use of Social Media (Attached)File: Evaluating Online Information (Attached)InstructionsReview the rubric to make sure you understand the criteria for earning your grade.Read chapter 6 in the textbook Applied Clinical Informatics for Nurses.Download and read A Nurse’s Guide to the Use of Social Media. (Attached)Download and view the Evaluating Online Information presentation. (Attached)Search databases for a current (within the past 5 years), peer-reviewed article that discusses ONE of the following: (a) Social considerations for personal healthcare information (PHI), (b) ethical considerations for PHI, or (c) legal implications for PHI. OCLS resources are preferred sources and can be accessed through IWU Resources. Wikipedia is not permitted, as it is not a peer-reviewed, scholarly source.Prepare to discuss the following prompts:Discuss barriers and constraints related to privacy and confidentiality practices in the healthcare setting. Share initiatives that you believe are helpful in addressing these identified barriers to HIPAA compliance. Use scholarly sources to support your discussion.Share information from your chosen article (see #5 above) with your classmates. Be certain to cite and reference the source.After completing the assigned readings on this topic, what initiative will you take in your own professional practice to improve on social, legal, and ethical practices? Be specific in describing this initiative.
IWU Ethical Considerations in Healthcare Organizations Discussion

Glucose Tolerance Tests Accuracy In Diagnosing Diabetes

According to the World Health Organization (WHO), more than 220 million people worldwide have diabetes. An estimated 1.1 million people died from diabetes in 2005, and almost half of diabetic deaths occurred in people under the age of 70 years of age. WHO projects that the number of diabetic deaths will increase to 366 million by the year 2030 (8). Diabetes Mellitus Type 2 is a prevalent disorder that causes one to have high blood sugar, or hyperglycemia. This hyperglycemia can be the result from one or a combination of 1) decrease production of insulin from beta cells of the pancreas; 2) increase sugar production from the liver; 3) decrease sugar uptake by cells secondary to insulin receptors. Symptoms of DMII are excess urination, excess thirst, dizziness, blurred vision, sweating, and fatigue. Patients presenting with these symptoms should be screened by a finger stick, where a blood sample is taken from a quick prick of the finger, to be tested for hyperglycemia. Normal blood sugar should range from 70-100mg. If one has a fasting sugar of >126mg or an after eating sugar level > 200mg, then an oral glucose tolerance test (OGTT) should be performed. During an OGTT, a patient consumes a 150-200g carbohydrate diet for three days and fasts from midnight prior to test date. The morning of test, the patient consumes 75g sugar mixed with 300ml of water within a 5 minute period. The patient’s blood sugar level is be measured at baseline, and then again at 120 minutes. A diagnosis of DMII is made if the baseline level is >126 mg and the 120 minute level is >200mg. These guidelines are set by the American Diabetic Association (ADA) and the World Health Organization (WHO) (1,8). Another option for obtaining a blood sugar level is measuring the percent of glycosylated red blood cells, or the percent of sugar attached to a RBC. RBCs live for approximately 90 days in the human body. By measuring this percentile one can observe the patient’s blood sugar level over the previous 3 months and not just at the moment an OGTT is performed. Today, HbA1c is a main tool for following metabolic control in persons with diabetes(5). A HbA1c > 6.0 percent should permit a diagnosis of DMII, but is not at this time a definite diagnostic tool. Diabetes can cause complications of multiple organ systems. WHO defines consequences of diabetes as follows: Diabetes increases the risk of heart disease and stroke. 50% of people with diabetes die of cardiovascular disease (primarily heart disease and stroke). Combined with reduced blood flow, neuropathy in the feet increases the chance of foot ulcers and eventual limb amputation. Diabetic retinopathy is an important cause of blindness, and occurs as a result of long-term accumulated damage to the small blood vessels in the retina. After 15 years of diabetes, approximately 2% of people become blind, and about 10% develop severe visual impairment. Diabetes is among the leading causes of kidney failure. 10-20% of people with diabetes die of kidney failure. Diabetic neuropathy is damage to the nerves as a result of diabetes, and affects up to 50% of people with diabetes. Although many different problems can occur as a result of diabetic neuropathy, common symptoms are tingling, pain, numbness, or weakness in the feet and hands. The overall risk of dying among people with diabetes is at least double the risk of their peers without diabetes (8). Previous studies have showed that better control of plasma glucose levels reduced the risk of developing long-term complications pertaining to diabetes (4). A higher HbA1c correlates well with the likelihood of developing chronic complications such as the ones listed above. This study is designed to explore if a HbA1c be used to diagnose diabetes. Observations suggest that a reliable measure of chronic glycemic levels such as HbA1c, which captures the degree of glucose exposure over time and which is related more intimately to the risk of complications than single or episodic measures of glucose levels, may serve as a better biochemical marker of diabetes and should be considered a diagnostic tool (2). As for the current gold standard for diagnosing diabetes, the oral glucose tolerance test (OGTT) has its limitations (2). These include high interindividual variability, low reproducibility compared to FPG, poor compliance with the conditions needed to perform the test correctly, and is cumbersome and time-consuming for medical staff and patients (4). Due to these factors one may ask, “Is a HbA1c or an OGTT more accurate at diagnosing new onset diabetes mellitus type 2 in a patient presenting with hyperglycemia?” By exploring this question and answering it from an evidence-based approach, the answer may help clinicians advance to an easier and less time consuming way to diagnose diabetes mellitus type II. CLINICAL CASE A 57 year old African American male presented to the outpatient office with symptoms of dizziness, blurred vision, polydipsia, and polyuria. He has a significant history of hypertension and hyperlipidemia. The patient was unclear when his symptoms started. Upon evaluation in the office, the patient was noted to have a marked glucose elevation of 420. An in-house HbA1c was also noted at 13.0. Upon further questioning, the patient has not been taking any medications for diabetes, and is currently taking Lisinopril and Zocor for his other medical conditions. Due to the presenting symptoms and lab results, the patient was admitted to the hospital for hyperosmolar nonketotic hyperglycemic state. METHODS A PubMed search was performed by using the “Clinical queries” and “Diagnosis” filters. The terms “A1c AND diagnosis AND diabetes” and “glycosylated hemoglobin AND diagnosis AND diabetes” were used to search the site for relating articles. With these search terms, a total of 176 hits revealed articles pertaining to the requested information. Articles that met all inclusion criteria for the research were evaluated and assigned a type/level of evidence. In order to be included in this evidence-based study, articles had to meet the following inclusion criteria: Articles must be cohort studies. Studies must not be > 6 years old. Articles must have participants with impaired glucose levels or symptoms of impaired glucose. Studies must include evidence of OGTT or FPG and HbA1c. Studies must have a significant number of participants to produce a significant result (n > 375). Any articles that did not specifically relate to diagnosing DMII with a HbA1c were excluded. Articles that were not cohort studies, were older than six years, did not have participants with impaired glucose, or did not have a significant amount of participants were excluded. Certain articles that appeared in the PubMed search were strictly review articles. These papers were reviewed, and if applicable, may be used to provided supporting factors about pathophysiology/ epidemiology of diabetes type II and its diagnostic criteria. Articles that met all inclusion criteria were evaluated and assigned a level of evidence using the Oxford Centre for Evidence-based Medicine Levels of Evidence worksheet. RESULTS Study #1: Diagnosing Type 2 Diabetes Mellitus: in Primary Care, Fasting Plasma Glucose and Glycosylated Hemoglobin Do the Job Study Design: This study was performed at the Raval Sud Primary Care Center in Barcelona, Spain and was begun in 1992. The purpose of this study was to determine the validity of glycosylated hemoglobin values as a method to diagnose type 2 diabetes mellitus in a population at risk seen in primary care. Four hundred fifty four subjects were selected to participate in the study. The population served by the Raval Sud Center is characterized by it low evonomic level, high rate of immigration, and high rate of morbidity and mortality for certain diseases and disorders. Inclusion criteria for eligible participants had at least on e of the risk factors for developing DMII described in the ADA guidelines. These included family history of DMII, personal history of carbohydrate intolerance or gestational diabletes, prolonged use of a drug able to raise glucose levels, obesity with a body mass index > 30, hypertension, HDL-cholesterol levels 250 mg/dL. Persons who did not wish to take part in the study were excluded. For the purpose of this particular study, data was recorded from the time the patient was included in the Raval Sud Care Center. The study then used a cross-sectional analytical design to validate a diagnostic test. (4) Study Conduct: Subjects were interviewed and variables were recorded for each participant. These included sociodemographic characteristics such as age and sex, clinical characteristics such as BMI and blood pressure, and laboratory values including fasting plasma glucose in a venous blood sample, oral glucose tolerance test after a 75g glucose overload, and a HbA1c measured by high pressure liquid chromatography. To standardize the results for the HbA1c, the absolute values were recalculated in terms of the number of standard deviations above the mean. FPG and OGTT values were based on the WHO criteria as having normal, impaired, or DMII glucose levels. (4) Study Results: The distribution of demographic characteristics and laboratory findings are shown in Table 1. The study found that plasma glucose levels were significantly lower in normal subjects than in subjects with abnormal glucose levels (IFG or OGTT) and even lower in subjects with abnormal glucose levels than in patients with diabetes (P< 0.001). Mean HbA1c values were significantly higher in patients with diabetes than in all other categories: 7.04% versus normal glucose- 4.98%, IFG- 5.42%, and IGT- 5.12% (P 5.94% (mean, 3SD), the diagnosis of DMII is reliable and accurate in 93% of the cases. Table 4 shows the diagnostic validity of a combined strategy of FPG and HbA1c values: patients were considered to have DMII when FPG > 125 mg/dL, or when FPG >110 mg/dL and HbA1c was greater than the cutoff value. Maximal efficacy (93% GV) was found for HbA1c > 5.94% (x 3SD), with a sensitivity of 92.2% and a specificity of 95.1%. (4) Study Critique: It has been confirmed that the relationship between circulating glucose values and the onset of chronic complications exists. Thus, it is logical for the diagnosis of DMII to be based on glucose values. One of the main problems in this particular study was to define and establish a cutoff point for this continuous quantitative variable. This study analyzed different cutoff points for the whole sample of patients at risk for DMII. When HbA1c values > 5.51% (x 2SD), were used for the cutoff point for diagnosis of DMII, the sensitivity (76%) and specificity (85%) were acceptable. However, when a higher cutoff point was used, specificity increased, but only at the expense of reduced sensitivity. Due to this situation, the study designed a strategy for diagnosis based on the FPG values and the validity of HbA1c. (4) Level of Evidence: 1c Study #2: Comparison of A1c and Fasting Glucose Criteria to Diagnose Diabetes Among U.S. Adults Study Design: This study included participants from the 1999-2006 National Health and Nutrition Examination Survey. Participants included 6,890 adults (>20 years of age), without a self-reported history of diabetes. The subjects attended a morning examination, fasted for > 9 hours at the time of their blood collection, and had valid plasma glucose and HbA1c values taken. Participants were categorized into one of the four groups by presence or absence of fasting plasma glucose > 126 mg/dL and HbA1c > 6.5%. The distribution of the population into these groupings was determined and the K statistic value was calculated. Also, the distribution of U.S. adults by fasting glucose and different HbA1c cutoff points (6.0-6.7%) were calculated. The objective for this study was to compare A1c and fasting glucose for the diagnosis of diabetes among U.S. adults. (6) Study Conduct: Data was collected through questionnaires (demographics, medical history), a physical examination (blood pressure, BMI, and waist circumference), and blood collection (lipids, plasma glucose, HbA1c). The plasma glucose was measured by using a modified hexokinase enzymatic method and the HbA1c using a high-performance liquid chromatography. (6) Study Results: This study concludes that an HbA1c of > 6.5%, along with a FPG >125 mg/dL demonstrates reasonable agreement for diagnosing diabetes. 1.8% of the participants were classified as having diabetes with a HbA1c > 6.5% and a fasting glucose >126 mg/dL. Among participants with a HbA1c 125 mg/dL, 45% had an A1c value > 6.0% but less than 6.5%. According to A1c guidelines, this value poses an elevated risk for diabetes. Table A1 shows a distribution of adults by fasting glucose and different HbA1c cutoff points. From this table, the lower the HbA1c cutoff points results in higher sensitivity and lower specificity. (6) Study Critique: In this study, certain participants had discordant results such as a HbA1c > 6.5% and a fasting glucose of < 126 mg/dL. These results may have been due to the fact that assessment of different aspects of glucose metabolism. For example, subjects with these results may have been diagnosed with an OGTT, which was not available for the majority of participants in this study. A comparison of these participants using the OGTT would have been a interesting assessment done by this study to compare with the FPG and HbA1c. (6) Level of Evidence: 1c Study #3: A1c and Diabetes Diagnosis: The Rancho Bernardo Study Study Design: The Rancho Bernardo Study included 2, 107 participants without known DMII, who had an OGTT and a HbA1c between 1984 and 1987. This cross-sectional study of community dwelling adults was provided written informed consent and laboratory data was performed. (3) Study Conduct: HbA1c was measured with high performance liquid chromatography using an automated analyzer. Ophthalmologic evaluation was also performed on the subjects. This was done by using nonmydriatic retinal photography. Sensitivity and specificity of HbA1c cutoff points for DMII were calculated, along with K coefficients which were used to test for agreement between A1c values and diabetes status. The objective for this study was to examine the sensitivity and specificity of HbA1c as a diagnostic test for DMII in older adults. (3) Study Results: For this study the HbA1c cutoff value was 6.5%. This value had a sensitivity of 44% and a specificity of 79%. A lower A1c cutoff point of 6.15% yielded the highest sensitivity at 63% but a lower specificity at 60%. If one were to use this cutoff value, it would miss one-third of those with DMII by the American Diabetes Association guidelines. It would also misclassify one-third of those without DMII. Using the HbA1c value of 6.5% as the cutoff point, the agreement with DMII diagnosis was low (K coefficient was 0.119). In order to compare A1c and ADA criteria with DMII complications, the study looked at participants with some degree of retinopathy. Of the participants who had retinopathy, 40% had and A1c > 6.5% and none had DMII by ADA criteria. This study concluded that the limited sensitivity of the A1c value cutoff may result in missed or delayed diagnosis of DMII, whereas the use of current OGTT criteria will fail to identify a high proportion of individuals with high A1c values, which correlate with long term complications of DMII. (3) Study Critique: This study was performed on a much older population than the other studies examined in this paper. It has its benefits and disadvantages for surveying a population in which there mean age was 69.4. The advantage is that the U.S. elderly population has the greatest current burden and is expected to have the greatest increase in the prevalence of DMII. On the other hand, the disadvantage to having such an older subject population is that it limited the HbA1c cutoff values to that particular population. In a previous critique of an article one of the concerns was the fact that there are different aspects of glucose metabolism. It would have been supportive if the article addressed the age of their participants and compared them with the study results. (3) Level of Evidence: 1c Study #4: Diagnostic value of glycated haemoglobin (HbA1c) for the early detection of diabetes in high-risk subjects Study Design: This study was performed by collecting data from the Bundang CHA General Hospital database. A total of 392 subjects who had an abnormal random plasma glucose, a history of gestational diabetes mellitus, a macrosomic baby, or a severe obesity were selected to participate in the study. Exclusion criteria included a previous history of diabetes of other endocrinopathies, pregnancy, abnormal liver or renal function tests, a history of major surgery, severe illness, blood transfusion within the previous 6 months, and weight loss > 3kg during the past three months. After an overnight fasting, blood samples were drawn from all participating subjects to include FPG and HbA1c values. (7) Study Conduct: Glucose concentrations were measured using the glucose oxidase method on a autoanalyzer. The HbA1c values were measured by the high-performance liquid chromatography method. All statistical analysis was performed and the best predictive cutoff values for FPG and A1c for detecting patients with new diabetes were identified using the optimal sensitivity/specificity values determined by the receiver operating characteristic curve. (7) Study Results: Figure 1 shows the ROC plot representing the sensitivity and specificity for the HbA1c and the FPG in detecting undiagnosed DMII. From this study, the optimal cutoff value for HbA1c was 6.1% and for FPG was 6.1 mmol/l. The sensitivity/specificity for the HbA1c cutoff value was 81.8% and 84.9% respectively. Table 1 shows the results from the combination of using FPG and HbA1c. This study demonstrated that HbA1c was very useful to screen for diabetes in high-risk patients and the combined use of HbA1c and FPG made up for the lack of sensitivity in FPG alone. (7) Study Critique: This study’s subjects were only Korean, therefore making the population very ethnically limited. It would have been beneficial to have seen the population more diverse and to notice the change in results. Also, the study stated that an OGTT was performed, yet a confirmation status of repeat testing was not recorded. This would have been beneficial to have in order to compare results to the FPG and HbA1c values obtained for cutoff for diagnosing DMII. (7) Level of Evidence: 1c DISCUSSION The purpose if this study was to assess if a HbA1c was sufficient enough to make a unknown diagnosis of diabetes mellitus type 2. From these studies one can gather that a HbA1c is adequate for making a new diagnosis for DMII. The following chart compares the specificity and sensitivity of each HbA1c from each study critiqued in this study. Also, each study uses a different HbA1c cutoff that they gathered from their cohort or cross-sectional study which is also included in the chart below. Study Sensitivity Specificity HbA1c used for Diagnosis Diagnosing Type 2 Diabetes Mellitus: in Primary Care, Fasting Plasma Glucose and Glycosylated Hemoglobin Do the Job 63.3% 93.4% 5.94% Comparison of A1c and Fasting Glucose Criteria to Diagnose Diabetes Among U.S. Adults 72.5% 96.5% > 6.0% A1c and Diabetes Diagnosis: The Rancho Bernardo Study 44% 79% 6.5% Diagnostic value of glycated haemoglobin (HbA1c) for the early detection of diabetes in high-risk subjects 81.8% 84.9% 6.1% Study #1 discussed the option of performing a combination of HbA1c and a FPG test. This exhibited to be most the most poignant result with a specificity/sensitivity of 92.2 and 95.1, respectively. In study #2, it also agreed that a HbA1c and a FPG level provided the most assured diagnosis for DMII. However, this study had the most discordant results and was probably due to the fact of its subject population. It stated that the results may have been due to the fact that assessment of different aspects of glucose metabolism was present (6). Study #3 was performed on a much older population, and focused on the importance of following HbA1c levels to help prevent long term complications of DMII. However, it also stated that a HbA1c would also have a higher sensitivity and specificity if it were performed along with a FPG test. Finally, study #4 agreed on the fact that a HbA1c was very sufficient for screening for DMII, and that it provided much support for diagnosing DMII along with a FPG. CONCLUSION This study provided that a HbA1c of approximately 6.0% is a great support to help making the diagnosis of DMII along with a FPG > 125. Some studies have suggested that a HbA1c of this value is suggestive of a diagnosis, however, the studies above advocate that FPG levels should also be obtained to solidify the actually diagnosis of DMII. However, in a recent publication from the JAAP, it states that”an A1c value of 6.5% higher as diagnostic. This value appears to be the level at which a person is at risk for developing the complications of diabetes. A diagnosis should be confirmed with a repeat A1c test, unless clinical symptoms and a glucose level higher than 200 mg/dL are present (5).” From this statement one can confer that the patient described above in the clinical case portion of this paper, does indeed warrant the diagnosis of DMII on the basis of a HbA1c of 13.0%, the presence of clinical symptoms, and the glucose elevation of 420 mg/dL.