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Much less information is available on sheep milk composition than on cow treatment tinnitus buy generic paxil 10 mg on-line, buffalo and goat milks medicine escitalopram buy paxil discount. Although some reviews cover both goat and sheep milks (Jandal medications with sulfur purchase paxil online from canada, 1996; Pandya and Ghodke medicine to increase appetite purchase cheap paxil online, 2007; Park et al. The higher lactose content is compensated for by lower sodium and potassium levels, although most of the other minerals are present in higher amounts in sheep milk, in line with the higher ash content. The average fat globule size is reported to be even smaller in sheep milk than in goat milk. As in goat milk, the non-protein amino acid taurine is reported to be present in sheep milk (Park et al. Yak milk the yak (Bos grunniens) is the only bovine reared in the mountainous regions of China, Mongolia, Russia, Nepal, India, Bhutan, Tajikistan and Uzbekistan, and hence the populations rely on the yak for milk, meat, fur and transportation (Wiener, 2002 cited in Silk et al. Several factories in China, Nepal and Mongolia produce dried yak milk for domestic consumption (Park and Haenlein, 2006). The proximate composition of yak milk is very similar to that of buffalo milk: the milks are significantly different (P < 0. Like buffalo milk, the fat content of yak milk is much higher than of cow milk, while its water content is more than 5 g/100 g lower. An analysis of published studies on yak milk showed that the water content can vary by as much as 10 g/100 g among samples of yak milk. Yak milk contains almost twice as much -lactoglobulin (average 708 mg/100 g) as in cow milk (300­400 mg/100 g). Yak milk was also reported to contain 67 mg of lactoferrin/100 g, 2­6 times more than values reported in cow milk (Krуl et al. Mare and donkey milks Mare (Equus caballus) and donkey (Equus asinus) milks are renowned for their therapeutic properties (Mittaine, 1962; Doreau and Martin-Rosset, 2002; Malacarne et al. Approximately 30 million people in Russia, Kazakhstan, Kyrgyzstan, Tajikistan, Uzbekistan, Mongolia and eastern and central Europe drink mare milk (Doreau and Martin-Rosset, 2002). These two monogastric species produce similar milk, with no significant differences between them (P < 0. According to some reports, mare milk Chapter 3 ­ Milk and dairy product composition 55 can contain up to 15 mg of ascorbic acid/100 g, much more than cow milk (Marconi and Panfili, 1998). The equine milks resemble human milk in their relatively low content of caseins (40­45 percent of total protein content). A recent study showed that caseins in equine milks are rapidly digested by gastric juices, in contrast to the caseins from cow and goat milks which are digested slowly (Inglingstad et al. As 40­50 percent of equine milk protein consists of whey protein, equine milk is not very suitable for cheese production. The whey proteins include lysozyme, which has been reported at 100­200 mg/100 g of donkey milk, compared with only 7­13 g/100 g of cow milk (Uniacke-Lowe, Huppertz and Fox, 2010). Although equine milk whey contains -lactoglobulin, the sequence homology between proteins isolated from equine milks and cow milk is only 60 percent. Owing to the similarity of milk proteins in equine and human milk, equine milks have been recommended for children with severe IgE-mediated cow milk protein allergy (Businco et al. Although one study documents the use of donkey milk to feed unweaned infants (Ziegler, 2007), further studies are needed, particularly because adverse effects on iron nutrition may be expected. The protein profile of equine milk makes it particularly suitable for consumption by people who are allergic to cow milk. There are two species of camel, the dromedary or Arabian camel (Camelus dromedaries, single-humped) mainly found in desert areas 56 Milk and dairy products in human nutrition in the Middle East, North and East Africa, Southwest Asia and Australia, and the Bactrian camel (Camelus bactrianus, two-humped), found in northwestern China and Mongolia, southern Russia, Tajikistan and Kazakhstan. Out of an estimated 18 million camels in the world only 2 million are Bactrian camels (Alhadrami, 2003). Camelids have a stomach with three compartments rather than four but with similar functional properties to ruminant stomachs (Schoos et al. The lactose and protein contents in the milk from the two camel species are similar but their fat contents are different, with Bactrian camel milk containing more fat. In overall proximate composition, dromedary camel milk is very similar to cow milk.

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The medication regimen may be less onerous symptoms queasy stomach and headache purchase 30mg paxil mastercard, but dietary and lifestyle changes are often harder to tolerate medicine runny nose purchase 10 mg paxil amex. The frequently reported absence of a strong relationship between adherence and glycemic levels may reflect the effects of physiologic characteristics medicine 1900s spruce cough balsam fir generic paxil 10 mg free shipping, such as intercurrent illness or hormonal fluctuations secondary to puberty treatment irritable bowel syndrome discount paxil amex. Metabolic control Psychologic traits and their impact on metabolic control these encompass a series of overlapping psychologic concepts that include "personality," "temperament" and "coping style. By contrast, HbA1c values tend to be higher in adults who are opportunistic and alienated [244] or who have poor impulse control, a propensity for self-destructive behaviors and difficulty maintaining interpersonal relationships [245]. Being a worrier or highly emotional, as reflected by elevated neuroticism scores or higher levels of trait negative affect, may also be associated with poorer metabolic control [246,247], although there is not complete agreement [248,249]. Individuals who have an "internal" locus of control believe that they are responsible for their health, whereas those who have an "external" locus believe that they are at the mercy of chance, or some other outside force. In general, individuals with an internal locus seem more likely to have better metabolic control [251­253], although that is not invariably the case [33,254,255]. One would expect that individuals with an internal locus of control would do a better job of managing their diabetes, and that this would lead to better metabolic control, yet most studies have failed to demonstrate a strong link between locus of control and adherence [252,256]. Reconciliation of these discrepancies may require a reconceptualization of the locus of control construct. For example, internal locus of control may have multiple dimensions such as autonomy and self-blame that are not typically measured in a systematic fashion yet may lead to somewhat different health outcomes [257]. Multidimensional measures that examine different aspects of sense of control as well as different modes of control and motivation for control may ultimately provide investigators with more accurate insights into the complex inter-relationships between perception of control and optimal diabetes management but, to date, they have been used only infrequently [258]. According to a systems model of health, there is no simple direct relationship between any single psychologic variable and metabolic control [242]. Rather, health outcomes are determined by a system of reciprocal relationships amongst multiple psychologic, behavioral and physiologic variables. Psychologic traits are relatively enduring characteristics that include personality, temperament and coping style. These may have a direct impact on self-care behaviors (adherence), and may also have a direct impact on emotional state. Psychologic states are more transitory and reflect emotions or feelings at a given point in time. Family functioning, including conflicts and degree of family cohesiveness, can affect psychologic state (and vice versa), but can also influence self-care behaviors. Self-care or adherence behaviors include medication use, diet, exercise and monitoring, and these 820 Psychologic Factors and Diabetes Chapter 49 low self-efficacy and high outcome expectancy tended to be in poorer metabolic control [259]. Problem-focused coping, in contrast, seeks to change the environment and thereby eliminate the threat. Within each of these categories, specific behavioral strategies may be differentially effective. Data from a meta-analysis of 21 studies have shown that the use of approach coping was associated with both better overall psychologic adjustment and with somewhat better metabolic control [264]. If traits truly reflect enduring behavioral characteristics, they ought to predict long-term adherence. Coping style assessed soon after diabetes onset predicted adherence behaviors 4 years later. Those children who used more mature defense mechanisms and showed greater adaptive capacity such as higher stress tolerance or greater persistence shortly after diagnosis were most likely to manage their diabetes satisfactorily in the long term. No experimental studies have systematically examined the relationship between chronic stress and long-term metabolic changes, and it remains possible that both indirect (behavioral) and direct (neuroendocrine) pathways are involved in mediating the relationship between heightened stress and poor metabolic control [242]. Investigators have also considered the possibility that high levels of stress may trigger the appearance of diabetes in genetically susceptible individuals [275]. Depression and anxiety has been found by some [284­286] but not all studies [45,73,256] to be associated with poorer metabolic control. Some of the strongest evidence for a link between affect and glycemic state comes from an early study in which adults with diabetes were followed during 36 weeks of treatment [287].

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People were given the wrong medication or dose Lack of communication between different multidisciplinary team members and with the person with diabetes treatment cervical cancer buy cheap paxil 40mg on-line. This led to basic failures in communication such as notification of both changes in timings of procedures and dosages of medications to the patient Lack of hospital staff knowledge of diabetes management both in terms of basic care and respecting patient autonomy Importance of people with diabetes being allowed to self-manage and thereby respecting the role of the person with diabetes in usually self-managing their condition on a daily basis Positive experiences of good diabetes management and proactively allowing patients to self-manage Box 32 medicine 8 soundcloud order paxil paypal. This can include physical or emotional harm [61] Medical errors are described as: the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim [61] 2 3 4 5 6 ally have a high level of knowledge about their condition medicine used to treat bv cheap paxil 10mg mastercard, are therefore often being managed by nursing and medical staff with only a rudimentary training in diabetes care [41] medicine park ok discount 40mg paxil with mastercard. Insulin prescribing and delivery errors Insulin treatment in hospital can be life-saving. It also has the potential to be life-threatening given its narrow therapeutic index. Insulin has been identified as one of the top five high-risk medications in the inpatient environment [42,43]. Medical errors, including those related to insulin treatment, are described as common in hospitals worldwide [44,45]. Insulin medication errors can occur at any stage in the process of prescribing, preparing and delivering the medication to the patient [46]. One-third of all inpatient medical errors that cause death within 48 hours of the error involve insulin administration [47]. In addition, if we are to identify those patients with undiagnosed diabetes and stress hyperglycemia and make an impact on their poor outcomes there needs to be a policy of routine blood glucose screening for all hospital inpatients. Ward environment factors Basic diabetes care is often not well delivered in hospital. The hospital environment is one that is characterized by instability and unpredictability for the patient. Despite the large numbers of patients with diabetes in hospital, the only mandatory training in diabetes is in blood glucose monitoring. People with diabetes, who gener- Medical prescribing A common recommendation emerging in both diabetes management and prescribing errors has been the need for appropriate medical staff education in diabetes and insulin treatment. Hellman [47] suggests that endocrinologists take on this role and maintain that junior doctors should be taught the principles of drug dosage and prescription writing before starting their ward placements. A report from the National Patient Safety Agency 2007 [49] devotes one entire page to insulin errors and advocates changes to pre-registration training to incorporate the principles and therapeutics of safe prescribing. The curriculum for junior doctors has been revised in recent years and new models of education have been implemented yet this has not reduced insulin prescribing errors in junior hospital doctors and therefore the process merits review. Aronson also called for the formation of an independent systematic review of medical prescribing and teaching by a multi-organizational body in order to inform practice. This process has yet to be implemented but if introduced could form the basis for training in diabetes medicines management. Delivering effective diabetes care: the role of diabetes inpatient team Diabetes inpatient teams are multidisciplinary; the health care professionals involved individually contribute specialist skills and together provide a holistic approach to patient care. As well as operating as a discreet unit, the team works closely with other medical specialities including the specialist diabetic foot team. The defined roles forming the diabetes specialist inpatient team include the following. Diabetes specialist dietitian Diabetes specialist dietitians have a pivotal role in the care of diabetic inpatients with complex nutritional needs, in particular those patients who are unable to swallow or those required to adhere to a complex dietary regimen as in renal failure, cystic fibrosis and the elderly. Other team members may include ward-based diabetes link nurses and diabetes specialist pharmacists. The majority of people living with diabetes have developed highly competent and individualized management skills, therefore it is essential, where possible, that the patient is encouraged to participate in the formulation and conduct of their own care plan while in the ward setting. The correct answer to this question is that all patients with diabetes should have access to specialist diabetes services; however, given that up to 20% of all inpatients now have diabetes then in real world it is going to be almost impossible for specialist team members to see every patient. Specialist teams therefore, driven by need, have drawn up a priority list for which patients should be referred for assessment. Consultant physician the primary role of the consultant physician is as leader of the multidisciplinary team. The consultant physician has ultimate responsibility for the clinical care of diabetes inpatients. With the need to maintain standards of care and update clinical guidelines, physicians are also frequently involved in audit and research work in order to ensure the highest quality of diabetes care for inpatients with diabetes. Hyperglycemia in hospital is a common problem and occurs in around 25% of all hospital inpatients. The majority of patients with diabetes are not admitted to hospital to address and treat complications associated with the disease.

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Non-sulfonylurea insulin secretagogues (glinides) Repaglinide is a benzoic acid derivative of the meglitinide class which predominantly lowers post-prandial hyperglycemia medicine ball abs generic 20mg paxil. It has a rapid onset of action and a lower risk of hypoglycemia than the sulfonylureas treatment varicose veins generic paxil 40mg amex, and achieves better post-prandial glucose profiles symptoms of mono safe 40 mg paxil. Repaglinide is predominantly metabolized in the liver to inactive metabolites and is safe in mild to moderate renal impairment medications not to be taken with grapefruit purchase paxil uk. Tablets can be missed if meals are omitted, and it may be effectively combined with metformin and with thiazolidinediones (where license permits). Nateglinide is a recent meglitinide which has a faster and shorter duration of insulin secretory activity than repaglinide but is less effective as monotherapy or in combination than rapaglinide. Insulin Recent improvements in the organization of care between hospital and primary care, and the expanding roles of diabetes specialist nurses and general practice nurses, have made it easier and safer to use insulin in the treatment of older people with diabetes [112]. Reported benefits include improvements in well-being and possibly quality of life [113­115] and in cognitive function [70], partly following improved glycemic control; however, others have found lower treatment satisfaction in insulin-treated patients [116]. Rapidly acting insulin analogs such as insulin lispro or insulin aspart may cause less hypoglycemia and weight gain, and can be given after eating where timing may be Table 54. Once-daily insulin regimens alone are now little used, except where glycemic control is not a priority or injections are impracticable. Insulin can usefully be combined with an oral agent in patients failing to be controlled by diet and oral agents. For frail subjects including those within care-home settings, complex regimens should be avoided so the use of longer-acting insulin analogs during the day often combined with oral agents is a feasible alternative. Low-vision aids are available to help to inject insulin, and some insulin pens have audible clicks for counting doses. Screen on admission for diabetes and regularly thereafter Policies must include strategies to minimize hospital admission, metabolic decompensation, pressure-sore development, pain, diabetes-related complications, infections and weight loss All residents with diabetes must have an annual review and access to specialist services Care-home diabetes policies must be developed nationally, locally and at the level of the resident with diabetes Research based on interventional strategies is needed mologists, and poor knowledge and training for care staff [120,121]. The impact of these initiatives is being followed on outcomes including well-being, metabolic control, access to regular review, rates of hospitalization and diabetic complications such as amputation and visual loss. Modern diabetes care for older people Diabetic patients in care homes In many developed countries the numbers of care-home residents are increasing and the prevalence of diabetes in this setting will inevitably increase. People with diabetes in care homes should receive care commensurate with their health and social needs [121]. The best possible quality of life and well-being should be maintained, without unnecessary or inappropriate interventions, while helping residents to manage their own diabetes wherever feasible and worthwhile. Metabolic control should reduce both hyperglycemic lethargy and hypoglycemia, with a well-balanced dietetic plan that prevents weight loss and maintains nutritional well-being. Foot care and vision require screening and preventive measures to maintain mobility and prevent falls and unnecessary hospital admissions. At present, residents with diabetes in care homes appear to be generally vulnerable and neglected, with high prevalences of macrovascular complications and infections (especially skin and urinary tract), frequent hospitalization and much physical and cognitive disability. This emphasizes the importance of early intervention in diabetic complications and of establishing rehabilitation programs for patients disabled by various complications such as amputation, peripheral neuropathy, immobility, falls, stroke and cognitive change. Health care must be cost-effective, which presents a difficult challenge for diabetes, because of its high prevalence, long duration of impact and wide spectrum of complications and emotional and psychologic sequelae; in older subjects, the challenge is even more complex because of the many other confounding factors. Hospital admissions of diabetic patients: information from hospital activity analysis. Improving the care of elderly diabetic patients: the final report of the St Vincent Joint Task Force for Diabetes. Some observations on sugar tolerance with special reference to variations found at different ages. Fast-track vascular work-up with early surgical referral Expected benefits Early detection/ management of vascular complications Optimized functional status Improved quality of life and well-being Functional assessment/active screening for complications programme Aggressive treatment of blood pressure and dyslipidemia Critical event monitoring Aggressive glucose control in acute myocardial infarction and stroke Developing rehabilitation programmes Figure 54. Recent studies [127­129] have suggested that aggressive treatment of diabetes in older individuals is not warranted because of their reduced life expectancy; however, implementing the strategies outlined above seems likely to reduce acute hospitalization, outpatient costs and long-term disability. Only well-organized prospective clinical trials will be able to determine how best to manage diabetes in older people. Ambulatory medical care for elderly diabetics: the Fredericia survey of diabetic and fasting hyperglycemic subjects aged 60­74 years. Use of hospital services by elderly diabetics: the Frederica Study of diabetic and fasting hyperglycemic patients aged 60­74 years.

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