Joe, a Filipino Rockssical: Play Review Essay

We were assigned to watch a stage play entitled Joe, a Filipino Rockssical last July 22, 2012 at St. Scholastica’s College, Manila. Actually, I have no interest in watching stage plays but after witnessing the presentation, my point of view changed. The play was about our national hero, Dr. Jose Rizal, but who is Rizal? For me, Rizal in this modern period is an instrument for us to love our country more despite of the dilemmas or struggles experiencing by it. Even our country had some flaws or imperfections, even the views and beliefs of others to our country were unlovely, we should still be proud and fight for it like what Rizal who’s brave as a lion did. He was also an inspiration to all youths because of his distinct attributes and his perseverance when it comes to studies. The stage play, Joe, a Filipino Rockssical is a kind of presentation wherein it was accompanied by songs and dances which is for me, an effective strategy because it can avoid boredom among the viewers. It has three chapters and used Filipino language for us to understand the play. It also used a little English and Espaà ±ol. This play was not a drama at all, it was also blended with comedy that can crack someone up and will make your jaws fall from laughter. But the most important thing is that it has a moral lesson that the viewers will realize after watching. The stage play was started through a lively song and dance. Six students of Rizal Integrated School were assigned to research and perform a stage play about our national hero, Dr. Jose Rizal, for the celebration of the 50th Foundation Day of the school. Joecas that symbolizes a man who values his craft more than anyone or anything else, is the writer and director, Joanne that symbolizes the character of having a principle and always with the truth, is the researcher, Hunter that symbolizes a character of having a principle and belief but can sacrifice it for the love of his life, is the composer of music, Bimbo that symbolizes a character that is persistent and diligent in reaching his dreams, is the choreographer, Ambo that symbolizes the character that is gleeful despite of his struggles especially when it comes to love, is the set designer, and Julia that symbolizes a character that has determination in reaching her dreams, is the fashion designer. They finished the play successfu lly although they have a little background or idea about the national hero. Ten years after, Joecas became a prominent writer. He was commissioned by the government to make and direct a stage play about the life of Rizal to be presented as a tribute for his 150th Anniversary of being a hero. Joecas together with his wife Joanne searched for his friends way back in high school to help him in the making of a stage play entitled Joe, the name that Josephine used to call Jose Rizal. Joanne became a successful researcher, Hunter became a rebel who climbed up in the mountains of Banawe, Bimbo became a DJ, Julia became a famous fashion designer, and Ambo owned a parlor. They have decided to stay at the condo of Joecas while finishing the play. During the researching and writing of the play, they learned many things about Rizal’s life. All the significant parts of the history about his live were presented. Some of these were about his love life including Josephine Bracken and Leonora, the writing of the novels that woke the consciousness of the Filipinos, the studying of Rizal abroad and here in Philippines, the exile of Rizal to Dapitan, the retraction of his ideologies to embrace again the Catholicism and to marry Josephine, and the shooting of him at Bagumbayan. The six main characters in the play also faced the different issues in their lives which are similar and compared to the life of Rizal. These consisted of the love of Joecas for Joanne and not sacrificing his love for art which is his true love, the love of Hunter for Joanne and the sacrifice of his ideologies, facing the true sexual preference of Ambo, consciousness of Bimbo about the problems of society, and Julia’s will of studying again. The conflict which is about the retraction was ended through a song and dance wherein the viewers were given the chance to decide whether Rizal signed the retraction or not. At the same time, they presented that even though Rizal signed it or not, what is important is that he had a stand about the ideologies and principles he’s fighting for and he kicked the bucket for the country. After all what happened, years passed, Joecas was given an award and honor for the stage play entitled Joe and he met his friends again during the event. The stage play was ended through a beautiful and magnificent music. In this play, many social illnesses are mentioned and shown and some of these are still occurring nowadays. In the dialogue stated by Ambo, â€Å"Palibhasa kabit ang nanay mo!†, is one of the social illnesses. It symbolizes a character of being a gossiper or spreading a speculation about a certain thing or person. It can cause a dispute or quarrel between the involved people. It can also cause disharmony or disunity. â€Å"I’m so fed up with the so called professionals, sobra na nga maningil wala pang work ethics. At sa sobrang dami ng raket, hindi marunong magcommit†¦Ã¢â‚¬  This was said by Joecas. It is one of the social illneses nowadays. Many people have too much confidence or belief in them, the belief that they are superb in terms of doing their work. Not only that, they are also asking for too much payment that is not appropriate, that’s why Philippines is not progressing. â€Å"Isipin na ang mabuting ina ay iba sa inang linalang ng prayle. Dapat palakihin ang anak na malapit baga sa larawan ng tunay na Diyos. Diyos na di nasusuhulan, Diyos na di masakim sa salapi, Diyos na ama ng lahat, na walang kinikilingan, Diyos na hindi tumataba sa dugo ng mahihirap, na hindi nagsasaya sa daing ng naruruhagi at nangbubulag ng matalinong isip.† These are the words mentioned at the back or the window of condo while Hunter and Joanne were fighting. The characteristics of God mentioned was contradictory to our government wherein it can be defined as another social illness. The scene where Ambo said that, â€Å"Hindi naman nasusukat sa sexual preference ang pagkatao at karakter. What is important is the heart and soul.† Judging a person is also one of the social illnesses acted in the play. The reason why most of the people do not believe in their talent is because they were primed by their anxiousness or shyness. The ability of a person is not measured by either physical appearance or sexual preference. In the scene where George Tauffer raped Josephine Bracken can be included as one of the social illnesses nowadays. Rape and other crimes are very rampant during these days. Sometimes, even their own fathers or stepfathers were the ones involved in this kind of situation. There are many barbarians in our country nowadays due to the lack of education or else because of drug addiction. The social illness like spreading information that is not proven or seen is very widespread nowadays. One example of this is occurring in the world of showbiz or show business. Many rumors are spreading in this industry that’s why it’s complicated. Those professionals that were taking too much charges or fees are also rampant nowadays that’s why the rich becomes richer and the poor becomes poorer. Similar to our government officials who live high on the hog, they were corrupting the taxes and other cash received from citizens for their personal use instead of giving it back in the form of basic services like education, health cares, and others. Criminals were also very rampant now and then but because police authorities like the friars before accept bribes, those culprits were not afraid to do crimes. These are some social illnesses mentioned in the play and at the same time I witnessed while watching. This stage play is not presented just to entertain but also to educate the audience. For me, having a stand in everything we do and say is the moral lesson that I have realized after watching. If we said and did something, continue it until the end as long as we know that we’re on the side of truth, although it can hurt those people that we loved the most. Another lesson derived from this play is the true love for the country. If our heroes can defend our country from opportunists and at the same time proud of it, we, the citizens of the Philippines, that have the capability to change the undesirable system of our government, can also do what they have done. It is the time for us to move and act especially the young generation that according to Dr. Jose Rizal is the hope of the nation.

An Occurrence at Owl Creek Bridge Essay

In Ambrose Bierce’s short story, ‘An Occurrence at Owl Creek Bridge,’ he uses his setting to carry out the plot of the story better than the short film of ‘An Occurrence at Owl Creek Bridge. ’ The words in the short story flow so beautifully, and give such detail as to fully understand the emotions running through Peyton Farquhar’s head as the time progresses to his hanging. In my opinion, the story’s graphic settings and imagery easily grasp the introduction rising action/climax, and conclusion as Ambrose Bierce originally wanted the story to be told. In the introduction of the short story, Bierce tells of a man, soon to be known as Farquhar, standing above a bridge engaged to be hung. As he is waiting for the lieutenant to complete preparations, he lays eyes upon a piece of drift wood in the swirling stream below the bridge. The story then goes into detail about how slowly the stream appeared to be moving the drift wood along, â€Å"He then let his gaze wander to the swirling water of the stream racing madly beneath his feet. A piece of dancing driftwood caught his attention and his eyes followed the current. How slowly it appeared to move! What a sluggish stream! (Literature 71). † However, in the short film it only represents the image of the piece of wood. This driftwood symbolizes the situation he is currently in; that he is in a chaotic predicament but is still able to ‘slowly drift’ through the problem. Therefore the story helps the reader fully grasp the introduction of the story better than the short film. During the middle of the story, before Farquhar’s last moments he thinks about his wife and children only to be interrupted by the sound of his pocket watch. As if time were slowing down in his last seconds, the interval between each tick is symbolic to how little time he has left. â€Å"Striking through the thought of his dear ones was the sound which he could neither ignore nor understand, a sharp, distinct, metallic percussion like the stroke of a blacksmith’s hammer upon the anvil.. the delays became maddening (Literature 72). † In the short film of ‘An Occurrence at Owl Creek Bridge,’ time speeds up and his pocket watch was taken from him by one of the officers, clearly not as in dept to relate why Bierce wrote the pocket watch into the story. Also during the rising action of the written story, it is told in great details of how he plunges into the water, and begins to swim through the stream. When he removes the noose from his neck, he sees himself performing but doesn’t follow through. He commands himself to place the cord back once he feels a sudden pang throughout his body, but his hands disobey him. This gives the reader inside details of the characters internal state, which is not expressed in the short film. Lastly, before it is known that Farquhar has been hung and this was his mind flashing through his last moments of life, the soldiers begin firing guns while he swims to safety downstream. At one point the written story tells of how he is spinning and whirled around in the water; which brings us back to the symbolism of the driftwood in the introduction. He spins round and round like the driftwood, finally caught up and not in control of the predicament he is in. â€Å"He had been caught in a vortex and was being whirled on with a velocity of advance.. spinning like a top (Literature 75). The film does not show the final symbolism of the driftwood and rushes through the stream to only have Farquhar advance to the bank and run through the forest to his wife and children. Therefore, in my opinion, Bierce’s written version of ‘An Occurrence at Owl Creek,’ uses the setting to advance the story and plot to the readers. It is more in dept and brings all things to light: internal state, physical state, symbolism, and his flashbacks. The introduction, rising action, and conclusion were all better carried out with setting in the written version rather the short film.

Crosby Manufacturing Corporation Case Study

AbstractNext to first-hand experience, case studies are one of the best ways to learn project management skills. In The Crosby Manufacturing Corporation case study, Harold Kerzner reports on the executive-level exchange between the company president and other department heads regarding a new Management Cost and Control System (Kerzner, 2009). This paper will give a synopsis of the case, analyze the case study communications issues and risks, and evaluate Livingston’s selection of a project manager. It will also discuss the possible reactions from the employees, the impact on the cost and time on the project as well as which constraints ultimately compromised the success of project.Crosby Manufacturing Corporation Synopsis of the CaseThe Crosby Manufacturing Corporation case study details a discussion between the organization’s executive officers over their plans to implement a new Management Cost and Control System (MCCS) (Kerzner, 2009). The president, Wilfred Livingst on, has successfully reorganized the company into a more efficient matrix organization over the previous three years and seeks to implement the new MCCS so the company can compete on new government contracts. Crosby’s existing MCCS falls short of government reporting and auditing requirements. At the beginning of the meeting, Livingston lays out the case for the new MCCS.The Management Information System (MIS) manager initially responds with a plan to perform a feasibility study with a detailed requirements analysis. The Engineering manager responds with a schedule and proposed vendor evaluation metrics. He suggested starting software development immediately. Livingston closes the discussion by assigning a project manager from another group and, after committing his support to the project, lays out a list of project planning items he wants to see the following week (Kerzner, 2009). Due to miscommunication,  Livingston’s plans cause potential risk to the projectâ€⠄¢s success.Evaluation of Livingston’s Choice of a Project ManagerThe President of the corporation had the right to decide on a project manager by employing an individual that would off the necessary services needed by the government agency to complete the job. Mr. Livingston gave the management staff an opportunity to come up with the proper approach but they were unable to. In line with the project objectives, they will fail to come up with the right milestones, detailed schedules, and design review meetings and feedback necessary from the management staff. As the leader of an organization, you have to be able to choose individuals as leaders that will be able to perform the task efficiently and effectively with the corporation’s best interest in mind. Was his choice a mistake?Yes, I think that this was a major mistake in appointing Mr. Emary as the project manager because he had little experience in such a major task and something that the company was depending on h eavily. Though Mr. Emary was an outstanding planner and got the job done, this was not one of those times when you need someone with little experience leading such a major project and to make the statement that Mr. Emary had less knowledgeable then other on the project did not do much to console the employees of his competence on completing the task.Reaction of the Functional EmployeesThe reactions from the functional employees in response to the appointment of Emary as the project manager had to be shocking. They probably had my questions and concerns about the potential success of the project and its completion under the supervision of Emary. Even if Mr. Livingston had confidence in his abilities, that said nothing about his ability to lay out the necessary and detailed schedule needed for the project completion or even know what resources were needed to be successful.Impact of Cost and Time RestraintsThe three constraints of project management will almost always be competing with each other. If a team decides to enlarge the scope of a project, the time will become larger as well, along with the cost. If the time  constraint is tighter, the scope may be reduced, but the costs will remain high. If the team should decide to tighten the budget, the scope will become smaller but the time will increase. To become skilled in project management, the project manager and their team must be capable of dealing with these constraints in a way that will allow them to successfully complete any project that they plan. This will have an impact on the kind networking techniques used and project schedules. Changes in projected costs to actual costs will in most instances stretch the length of time it takes to complete projects and at the same time determine the kinds of techniques to be employed.Constraints that could Compromise Project SuccessAlthough there are many project constraints, these should not be barriers for successful project execution and for the effective dec ision-making. The main three interdependent constraints for every project are time, cost, and scope. Quality is not a part of the project management triangle, but it is the ultimate objective of every delivery. Hence, the project management triangle represents implies quality. Many project managers are under the notion that ‘high quality comes with high cost', which to some extent is true. By using low quality resources to accomplish project deadlines does not ensure success of the overall project.So like with the scope, quality will also be an important deliverable for the project. The important aspect is to deal with it. The project manager needs to strike a balance between the three constraints so that quality of the project will not be compromised. To overcome the constraints, the project managers have several methods to keep the project going. Some of these will be based on preventing stakeholders from changing the scope and maintaining limits on both financial and human resources. A project manager's role is evolved around responsibility. A project manager needs to supervise and control the project from the beginning to the closure. Understanding that it is always a requirement to overcome the challenges related to the project and if you do so, those constraints will not ultimately compromise its success.

Domestic Violence During Pregnancy Research Paper

Domestic Violence During Pregnancy - Research Paper Example                                  Domestic Violence During Pregnancy Introduction: This paper aims to discuss various effects of domestic violence during pregnancy. Domestic violence is becoming an epidemic in almost every part of the world. This is a public health issue, seriously affecting the health of women. According to a recent report by a US daily, out of 33 developed countries, the United States is in the 27th position for life expectancy after birth. â€Å"Pregnancy is a time when friends, family, and health professionals expect a woman’s partner to be particularly concerned about and attentive to her health and well-being. It is difficult to imagine that anyone, let alone the father of the baby, would intentionally injure a pregnant woman, thereby jeopardizing her health and the health of the fetus† (Humphreys & Campbell, 2011, p. 155). In a recent government health plan call â€Å"Healthy People 2020† released by the U.S. Departmen t of Health and Human Services mentioned that domestic violence during pregnancy is found out to be the cause of complications like pre-term birth or low birth weight-outcomes. This type of violence also can cause various risks of maternal, prenatal and child health, miscarriage, infection, fetal injury and fetal death. While domestic violence occurs, injuries to the abdomen, breasts and genitals are some of the common factors. Apart from these physical risks, abusing during pregnancy can cause end number of psychological consequences like depression, stress and dependence to tobacco, drugs and alcohol. â€Å"Common sense demands that pregnant and nursing women minimize their exposure to xylene, just as they should minimize their exposure to alcohol, tobacco and other drugs† (Pregnancy, 2007, p. 68). Apparently, these psychological consequences affected the baby most as the majority of the time the mother losses attention in her or her baby’s physical condition, both t hrough the pregnancy and following the child is born. â€Å"One study found that 15 percent of women were assaulted in the first four months of pregnancy and 17 percent were physically abused during the last five months of pregnancy† (Sterne et al. 2010, p. 48). Nursing Care Consideration to Domestic Violence: What Nurses can do? Research found that around 324,000 pregnant women in the United States are battered by their intimate partners every year. Hence, there is a need of creating awareness against domestic violence during pregnancy keeping in mind the fact that domestic violence is becoming the largest cause of injury for women in the United States. As per nurses are concern, all nurses and health care professionals of all specialties are likely to assist help to the women sufferer of domestic violence. Nurses must assure the sufferer a proactive assistance to this dilemma. They should involve themselves to treat the sufferers of domestic violence. They should take a hel pful and empowering approach towards the patients. While assessing the patient who faced domestic violence, it is very necessary for the nurses to create a believing and accepting environment, so that the patient does not lose her self esteem. Various researchers found that believing, accepting and supporting patient by the nurses can improve the psychological healing of such patients. What are the impacts of battering to the individual client, newborn and the family? Although there are lots of literature reviews, the impacts of domestic viole

Principles and Practices of Effective Leadership (Apple Inc) Essay

Principles and Practices of Effective Leadership (Apple Inc). Leadership Portfolio - Essay Example Each leader adopts a unique approach and style, through the interplay of one’s traits, intelligence, behavioral set, authority, power, temperament and charisma. Within an institution, there develops an emphasis on implementing leadership skills and abilities that are relevant across the organization. This cultivates the ‘leadership style of the organization’. Let us delve in to an analysis on leadership at Apple Inc. (formerly  Apple Computer Inc.), an American  multinational corporation that designs, develops and sells  consumer electronics, computer hardware, software and personal computers. The powerful visionary, Steve Jobs, was the co-founder of Apple Inc. along with Steve Wozniak. They went on the establish Apple as one of the world’s giants, with an unconventional approach and leadership style that was starkly different from conventional business wisdom. The predominating leadership approach at Apple Inc. was that of ‘Transformational Lea dership’, wherein Steve Jobs (the leader),  identified the need for  change,  created  a vision amongst his people to enforce the change and  finally, ensured its enforcement with the  unfailing commitment  of the  members  of his company. (Bryant S., 2012)... At a review session, Jobs was quick to grab a ‘Magic Marker’ and draw a two-by-two grid on the board, labeling each quadrant sequentially as â€Å"Consumer†, â€Å"Pro.†, â€Å"Desktop† and â€Å"Portable†. He insisted that Apple focus on just four great products (one for each quadrant), cancelling all other products. Steve Jobs is known to have said to Walter Isaacson, â€Å"Deciding what not to do is as important as deciding what to do. â€Å"That’s true for companies, and it’s true for products.† (Issacson, 2012). The Apple Company under Steve Jobs, developed a ‘perfectionist style’ with an eye for great detail. The success of the company lay in the fact that Jobs recognized his own strengths and delegated areas suited to other people’s strengths, so that only the best product emerged from its shores. Steve Jobs was a driven leader and the products and services he directed his company to develop and commercialize changed the way many of us live, as well as the course of a diverse set of industries, including computing, publishing, movies, music and mobile telephony (Katzenbach, 2012). Undoubtedly, the success of Apple Computers under Steve Jobs stemmed from his creativity in decision-making, charismatic leadership and the ability to take risks in order to adapt to changing market conditions. As testimony to Apple’s creativity, Steve Jobs himself famously said â€Å"innovation distinguishes a leader and a follower†! Both, situational factors and the leadership approach of Steve Jobs contributed to Apple’s success. By selecting Steve Jobs to lead the company, Apple was not only able to improve its performance, but also position itself to take advantage of the opportunity

The culture of China Mafia (triad) Essay Example | Topics and Well Written Essays - 500 words

The culture of China Mafia (triad) - Essay Example Although clans have the same hierarchical triad structure, each one of them operates separately from the others, and each one can undertake a business, without asking the consent from the other (Booth 78). An important rule of these triads that can be also related to other organized crime organizations around the world is that women are prohibited to infiltrate in such societies. Moreover, their culture is based mainly on loyalty, because all members develop family ties and should pass an initiation process. In what concerns the profile of members of such societies, some of them are very educated (e.g. lawyers and accountants), who are using their professional status for illegal businesses (Lintner 88). These professionals are not under the possibility of being arrested because the police are focusing on the street criminals, and not on the legitimate lawyers and accountants (Chow 478). When assessing the culture of triad societies is important to overlook the main domains in which they operate. Chinese clans operate mainly in the area of heroin trafficking, but also on counterfeiting goods and human trafficking. The cities with the highest presence of triads are Hong Kong, Macau, and Taiwan. The functioning of Chinese triads has also been based on a strong connection or association with the government, mainly because of the communist regime of this country. An example of this kind of association happened in 1992 when Tao Siju (which was minister of public security) encouraged the patriotic work of clans, and set up the framework to continue their businesses, considered in the interest of the state (Brodhurst and Wa 12). Nowadays, it is also necessary to discuss the activity of these triads and to see if law enforcements and other measure had an impact on the culture of these triads and the way they operate. It has been seen an improvement in combating triads activity in Southern China due to a rapid economic development in this

Finish homework Assignment Example | Topics and Well Written Essays - 500 words - 1

Finish homework - Assignment Example This essay is a rhetorical analysis of the 2013 documentary,Blackfish. Production of the documentary Blackfish intended to show the dangers of placing in captivity of clever and emotional creatures such as whales. To achieve this, Blackfish shows a series of mistreatments of whales in captivity in various performing parks around the world, concentrating on the devastating incidents that led to the death of four people. This documentary mainly uses a killer whale known as Tilikum due to his involvement in three of the four deaths. Since Tilikum cannot tell the story, a collection of former orca trainers particularly those who worked with Tilikum are used. The use of orca trainers as the narrators, places their stories above those of Tilikum. This way, Blackfish turns out to be a narrative with two main points. The first point is that the idea of keeping killer whales in captivity is wrong and the second point is that the abuse of whales by fellow whales whiles in captivity maybe the reason some of them become hostile. Blackfish director Gabriela Cowperthwaite excelled in this documentary particularly the perfect visual work. The documentary uses skilled cinematography to blend interviews with actual shots of the animals and parks, and the occasional pieces of created shots for instance the animations employed in presentation of courtroom transcriptions. This makes Blackfish a stunning work of visual art that most people will enjoy watching and since it provides fresh content in a rare form of cinematography. The soundtrack by Jeff Beal in this documentary greatly improves the visual power of the film by heightening the documentary’s emotional thrust. This masterful soundtrack therefore, helps the documentary in successful manipulation of the audience’s emotions. Blackfish however fails to align its ideas in a manner that clearly

Australian Wine Exports to the Market of the USA Assignment

Australian Wine Exports to the Market of the USA - Assignment Example In this market, when the supply of one currency decreases, the demand for the other currency simultaneously falls. When the Australian exports of wine to the US market decrease, this indicates that US citizens are supplying less US dollars to buy less of Australian dollars in exchange which are required to buy a smaller quantity of exports. This, in turn, will lead to a depreciation in the foreign exchange value of the Australian dollar. (Jackson, McIver, Wilson 2011) (2) A strong Australian dollar indicates a high value of the currency with respect to the other currencies of its partner trading nations. When the Government maintains a strong currency, it prevents the currency from evaluating. Under the Aggregate Expenditure Model: If Australia maintains a strong currency, its trading partners will be discouraged to buy Australian exports. Therefore, the value of the country’s exports will fall. Thus in equation (1), X falls. Since X is an important determinant in the Aggregate Expenditure of an economy, a decrease in X causes the AE of Australia to fall. The AE, in turn, determines the GDP of the country. With a decrease in AE, the GDP of the nation will decrease. A decrease in the GDP cannot be a healthy sign for an economy. Thus, if Australia maintains a strong currency this might prove to be a threat to the overall economy of the nation. In the short run, this will have a positive effect on the Balance of Payments (BOP). The advertisement campaign will make Australia’s regional wines more attractive to the US customers and they will buy more of this wine. Thus Australia’s export of wine rises, i.e X rises. In the short run, exports will increase in Australia’s Balance of Payments and the exchange value of the Australian dollar will appreciate. In the long run, the effect of an increase in investment will be ambiguous.  

Communication - Upward Distortion Research Paper

Communication - Upward Distortion - Research Paper Example Hence instead of giving accurate information to the top management, employees often pass distorted information to the seniors/boss which often referred as the upward distortion of information in the organizational world. â€Å"It has long been recognized that employees are prone to distort the messages they transmit upwards, with deleterious effects on general climate issues and overall organizational functioning† (Tourish & Robson p.18). This paper analyses different aspects of upward distortion of information in organizational world. Distortion is anything that contributes to alterations in meanings as messages move through the organization. Distortions can occur for a variety of reasons, due to â€Å"load, message direction, channel usage, and the very composition of the [communication] networks themselves. It is no exaggeration to say that distortion is inevitable and unavoidable (Durden) As mentioned earlier, information is always passing from bottom to top (from employe es to management) and from top to bottom (from management to employees) in an organization. Moreover information exchange can take place horizontally also (between the employees). ... When the employees distort some information while communicating with their employers; it is termed as upward distortion. Same way while employers distort some information, it is termed as downward distortion. â€Å"Distortion of upward communication negatively related to the level of security and positively related to achievement needs; also positively related to the heteronomous organizational climate and negatively related to an autonomous climate† (Athanassiades). In other words, whenever an employee feels insecurity in passing certain information to the top, he will try to distort or twist it. Same way, whenever an employee likes to get some benefits from the organization, he will try to distort the information. Distortion of information occurs when the employees or the employer wants to protect their interests. For example, suppose a sales executive was heavily criticized by an important client of an organization for the delayed delivery of a product or service. In such c ases, the executive will never pass such information to his manager or boss. In other words the fear of consequences forced the employee to distort the information. He will inform his manager that the client was extremely satisfied by the product or service delivered. He will never say anything about the delays caused in the delivery and the subsequent unhappiness developed by the client. If the executive passes the information about the delayed delivery of the product or service to his manager, he will sometimes get punishments from the top. At the same time, if the executive was ready to provide such information, the manager could have taken measures to cool down the temper of the frustrated or unhappy client. It is quite possible that the client may rely on other product or service providers

Models in project management Essay Example | Topics and Well Written Essays - 750 words

Models in project management - Essay Example This statement of work will provide a deep insight into development of the high-level project charter for the E-Mail Upgrade Project described in the scenario. This statement will provide an overview of the identification of a project management methodology and project team, and a baseline schedule. This will describe the project objective and its main scope. This project is going to enhance the overall structure if the company communication structure. This project will upgrade the e-mail system of the Ohio Department of Human Services. Through this the organization will get the better communication facilities and data sharing network over the organizational intranet. This project will enhance the following areas of the organization; This project will be implemented on the Ohio Department of Human Service’s organizational Intranet. The Office of Network Support (ONS) will keep track and manage the overall project and its associated activates (tasks, phases). We have decided to purchase the new version of the Worldviewupgrades that is Globalupgrades 9.0. This is better system with the offer of discounts for a Version 9.0 license. We are also satisfied with the quality of this system working. This system will also offer the better robust working environment. I have analyzed the overall project tasks and main activities that we will need to perform. After this I have devised a workable and convent time line for this project. This project will take three months for the overall project execution and implementation. At the end of the three months we are expecting to have the overall new efficient working system that will deliver the better performance and communication infrastructure. After that we have to engage a training period of three days that will introduce the all personal regarding the use of the new system. This system should have the capability to tolerate any system level error. This system should also

Employment - Management Essay Example for Free

Employment Management Essay For the longest time I could not decide on a major and a career to study throughout college. When I came to Georgia Southern University I discovered that they had a major that was very interesting to me. Sport Management id the ideal major for my interest and me. Since I love sports I figured that this would be the career for me. A degree in Sport Management helps to prepare for success in sport related occupations. The job market varies in the field of sport management. Some occupational opportunities include: athletic trainer, coach, sports official, Sports agent, camp director, sporting goods sales/dealer, pro scout, athletic director, sport promoter. The list can go on of the opportunities in this career. Mostly anything sport related in todays business world is included also. The nature of a person in a sport management career is based solely around sports. Depending on what occupation you decide to pursue the work and conditions will differ. Some typical activities are, plan and direct athletic events, represent professional athletes, plan and direct the training of the team players, evaluate skills and potential of players, or work extensively with players, coaches, officials, managers etc. The work condition can vary with different jobs or tasks. A scout will be called on to travel about 3/4 of the time. Athletic directors handle the athletics of their prospective schools along with coaches. A sports agent working conditions can involve a lot of long hours and extended pressure. Some employment settings are colleges/universities, camps, sporting goods stores, management firms, professional teams, fitness centers and the media. The job outlook for most careers in Sport Management is fair to good. Sport Management is one of the fastest growing fields of study in the country. With that there will lots of job openings and new businesses starting. Some jobs in this field are limited. For instance, anything dealing with professional teams is limited due to the number of sports teams. Successes in the teams help with salary and benefits for the employees. Most jobs in the sport management field are setup to where an employee must work his or her way up the ladder. For example, the job may ask the employee to assist in work and the salaries are not as high. In some jobs such as being a general manager of a professional team the job is to an extent being in the right place at the right time. Careers in sport management require some necessary in order to be successful. Being able to communicate effectively is a very important skill in this career. Giving Speeches is one part of communication that is important. Decision Making, Organizing, Leading/Coordinating and being able to motivate others is also critical in the career. Qualifications for most jobs require a bachelors degree, sport experience and management training.

The Gospel Of St. Paul Essay Example for Free

The Gospel Of St. Paul Essay The Apostle of the Gentiles as Saint Paul is revered as, is a persecutor of the followers of Christ, of Christians. It was on his way to Damascus that Jesus Christ revealed Himself to Saul (the Jewish name of Paul). It is in Chapter 22 of the Book of Acts that the incident was narrated when Jesus Christ asked Paul as to why Paul is persecuting the Lord. Hence, the Lord Jesus commanded Paul to go to Ananias where Paul got the message that the Lord has chosen him to spread his Word and declare His name to all pagans and Kings and nations. This revelation that brought about the conversion of Paul is due to the spirit of the Lord Jesus Christ to have dwelt in Paul. Paul awakened to the distinction of the life he wishes and is destined to pursue as a Christian compared to his life as a Jew. Being born with the spirit of Jesus Christ at that instance and thenon caused the Word of God to dwell in him It was immediately clear to Paul who is Jesus Christ and how he will communicate to the whole world about him. It is a paramount teaching and admonition of Saint Paul that mankind should listen to the spirit, as he wrote his First Letters to the Thessalonians (Chapter 5 Verse 13). Paul thus was fully empowered and authorized to spread the Word of God and the Knowledge of God. â€Å"Paul sees himself as a charismatic. Consequently his proclamation rests on the power of the spirit and is accompanied by signs and wonders. He was given the grace of the apostolic office. Through this he has special authority that he can exercise with regard to the church, even if he makes only reluctant use of it. † After the conversion and baptism of Paul in Damascus he went to Arabia to prepare for his mission. He returned to Damascus and started preaching which enraged the Jews. Feeling the threat of such anger, Paul visited Peter and the other apostles in Jerusalem. It was Barnabas who introduced Paul to Peter and the other apostles, declaring that Jesus Christ revealed himself to Paul and spoken to him and that Paul had already preached in the named of Jesus Christ. So when Peter and Paul met together with James, Paul learned from them everything about the resurrection of Jesus Christ. Peter narrated how the event happened and proven as Jesus Christ revealed himself as alive and risen from the dead to hundreds of people So, together with the 12 apostles and the witnesses to Christ’s resurrection, Paul considers his enlightenment as a way of tradition which he relays to those he converts to follow Jesus Christ. â€Å"Tradition was a living and growing thing in the first-century church: the tradition which Paul delivered was fuller than what he received, for he was able to amplify the record of appearances of the risen Lord with his personal testimony. † Peter and the rest of the apostles were wary about Paul as he was known to be a persecutor of Christians. Yet, they all felt and believed that they are indeed being made to be united for the mission that is to declare the Word of God. Paul and the apostles met with the Council of Jerusalem where they encountered the profound issue of the Mosaic Law – the commandments of God has handed down to Moses. One of the mandates that the Jews standby firm is that salvation will only be attained after circumcision in the manner of Moses. The law must be strictly adhered to and the people of Jerusalem believes no other means to heaven. â€Å"The law had a special relationship with Israel, particularly to protect and discipline Israel in the period from Moses to Christ. But that was a temporary role. It should not be assumed, however, that this is the only function of the law and therefore that the coming of Christ means the abolition of the law† Yet, Paul heard how Peter has explained that belief and living by the Word of God in the way Jesus Christ has taught and exemplified and lived and died for is the true message of salvation. It is in such faith, Peter and the apostles thus attested that God’s miracles and wonders that they have seen and done were made possible. It is to adhere to the Word of God and at the same time avoiding all sins of idolatry and lusts. Paul was further enlightened on what Jesus Christ gospels and teachings are geared to. That God is a forgiving and all knowing God. His Divine Plan for mankind is to live in peace and love amongst each other and to revere His Divinity as one and absolute. And as Paul went about his ministry to propagate the faith in such accord, he was known for the solidity of his thoughts, the fluidity of his message and the sanctity of his feelings for mankind. â€Å"Paul’s theology of God was no abstract speculation but sustained and informed by his own experience in conversion and mission and prayer. It is the integration of intellectual rigour, missionary and pastoral effectiveness, and personal experience which makes his speech about God so compelling. † Paul’s teaching about the goodness of God as exemplified in giving to the world His Only Son by dying on the cross. Yet he expounded on the lesson that death from this life is a transition to another, better life. Paul achieved the realization as he painstakingly preached that Jesus Christ proved that it is in dying that man is born to eternal life. â€Å"The power of Christianity inspired by this faith in the resurrection of Jesus Christ, it is hard for us now to realize. Eighteen centuries have intervened between our selves and the living witnesses of the resurrection. But then they were living. And yet there were difficulties which Paul had to encounter, and many of them. It was not plain or easy work. † Thus, the preaching method of Paul ventured on showing and demonstrating the goodness he experienced in his vision of Jesus Christ. His change and his commitment to the Lord were all gifted to him. Jesus Christ became the only basis of his interpretation of the goodness of God; what a true relationship to God is all about. It is because as Paul explained in his Letter to the Galatians in Chapter 1, Verses 12 to 16, his enlightenment and conversion and mission do not come from man but from Jesus Christ. â€Å"The connotation of communicated knowledge is reinforced by the fact that, strictly speaking, what is revealed in v. 12 is the ‘good news’ whereas the purpose of the revelation in v. 16 is ‘to preach good news’. In Paul’s case, conversion and call to ministry are inseparable† Bibliography: Abbott, Lyman. The Life and Letters of Paul the Apostle Boston and New York Houghton, Mifflin and Company The Riverside Press, Cambridge, 1898 Becker, Jurgen; Dean, O. C. ; Soards, Marion L. Paul: Apostle of the Gentiles Westminster John Knox Press, 1993 Bruce, Frederick Fyvie. Paul, Apostle of the Heart Set Free Wm. B. Eerdmans Publishing, 2000 Dunn, James D. G. The Theology of Paul the Apostle Wm. B. Eerdmans Publishing, 2006 O’Connor, Jerome Murphy- Paul: A Critical Life Oxford University, 1997 The Holy Bible. King James Version New York: American Bible Society, 1999 New York: Bartleby. com, 2000

Sodium, Potassium and Urea Measurement

Sodium, Potassium and Urea Measurement Introduction Electrolytes are solutions that conduct electricity. Any molecule that becomes an ion when mixed with water is an electrolyte. Salts such as sodium, potassium, calcium and chloride are examples of electrolytes. When these molecules dissolve in water, they release ions with an electric charge, positive or negative, that attracts or repels other ions during a chemical reaction. In living cells, most chemical reaction occur in an aqueous environment since approximately 75% of the mass of the living cell is water. Normally 70kg man, represent with 42 litres of total body water that contribute for about 60% of the total body weight. (Marshall, 2000). 66% of this water is in the intracellular fluid (ICF) and 33% in the extracellular fluid (ECF). The principle univalent cations in the ECF and ICF are sodium (Na+) and potassium (K+) respectively. Sodium (Na+) Sodium is the major cation of the extracellular fluid (ECF). It represents almost one-half the osmatic strength of plasma. It plays an important role in maintaining the normal distribution of water and osmatic pressure in the ECF compartment. Sodium levels in the body are regulated ultimately by the kidneys (it excrete excess sodium). The main source of sodium is sodium chloride (NaCl- table salt) which is used in cooking. The daily requirement of the body is about 1 2 mmol/day. Sodium is filtered freely by the glomeruli. About 70 80 % of the filtered sodium load is reabsorbed actively in the proximal tubules (with chloride and water passively) and anther 20 25 % is reabsorbed in the loop of Henle (along with chloride and more water). Normal ECF sodium concentration is 135 145 mmol/L while that of the intracellular fluid (ICF) is only 4-10 mmol/L. sodium is lost via urine, sweat or stool. (Marshall, 2000). Hypernatraemia Hypernatraemia (high sodium levels in the blood) may occurs due to increase sodium intake, decrease excretion, dehydration (water loss) or failure to replace normal water losses. It can also occurs because of excessive mineral corticoid (such as Aldosterone) production acting on renal reabsorption. The clinical features of hypernatraemia are non-specific or masked by underlying conditions. Nausea, vomiting, fever and confusion may occur. A history of long standing polyuria, polydipsia, and theist indicates diabetes insipidus. Hypernatraemia is caused by many diseases such as renal failure, Cushings syndrome or Conns syndrome. Conns syndrome is a disease of the adrenal glands involving excess production of a hormone, called aldosterone. Another name for the condition is primary hyperaldosteronism. Hyponatraemia Hyponatraemia (low sodium levels in the blood) is caused by impaired renal reabsorption of sodium. This occurs in Addisons disease of the adrenal gland due to loss of aldosterone producing zona glomerulosa cortical cells. Sodium decreases in severe sweating in a hot climate or during physical exertion such as marathon running. Falsely low serum sodium concentration may be found in hyperlipidaemic states where the sodium concentration in the aqueous phase of the serum is actually normal, but the lipid contributes to the total volume of serum measured. The symptoms are non-specific and include headache, confusion and restlessness. Hyponatraemia is seen in Addisons disease and/or excessive diuretic therapy. (Kumar Clark, 2002) Potassium (K+) It is the major intracellular cation. It is average concentration in tissue cells is 150mmol/L and in RBCs is 105 mmol/L. The body requirement for K+ is satisfied by a dietary intake. K+ is absorbed by the gastrointestinal tract and distributed rapidly, with a small amount taken up by cells and most excreted by the kidneys. Potassium which filtered by the glomeruli is reabsorbed almost completely in the proximal tubules (PT) and then secreted in the distal tubules (DT) in exchange for sodium under the influence of aldosterone. Factors that regulate distal tubular secretion of potassium include intake of sodium and potassium, water flow rate in distal tubules, plasma level of mineralocorticoids, and acid-base balance. Renal tubular acidosis, as well as metabolic and respiratory acidosis and alkalosis also affect renal regulation of potassium excretion. (Kumar Clark, 2002). Hyperkalaemia Hyperkalaemia is high K+ levels in the blood. Potassium is in high concentration within cells than in extracellular fluids. This means that relatively small changes in plasma concentration can underestimate possibly larger changes in intracellular concentrations. In addition, extensive tissue necrosis can liberate large amounts of potassium into the plasma causing the concentration to reach dangerously high levels. The commonest cause of hyperkalaemia is kidney failure causing decreased urinary potassium excretion. Severe hyperkalaemia (> 6.5 mmol/l) is a serious medical emergency needs treatment as fast as possible because of the risk of developing cardiac arrest. Moderate hyperkalaemia is relatively asymptomatic emphasising the importance of regular biochemical monitoring to avoid sudden fatal complications Hypokalaemia Hypokalaemia (low potassium levels in the blood) has many causes; the most common are diuretic treatment (particularly thiazides), hyperaldosteronism and renal disease. Hypokalaemia is often associated with a metabolic alkalosis due to hydrogen ion shift into the intracellular compartment. Clinically, it presents with paralysis, muscular weakness and cardiac dysrhythmais. (Kumar Clark, 2002) Aldosterone Aldosterone is a steroidal hormone secreted by the adrenal cortex. It is the hormone that regulates the bodys electrolyte balance. This hormone synthesized exclusively in the zona glomerulosa region of the adrenal cortex. This zona contains 18-hydroxysteroid dehydrogenase enzyme which a requisite enzyme for the formation of Aldosterone. Aldosterone acts directly on the kidney tubules to decrease the secretion rate of sodium ion (with accompanying retention of water), and to increase the excretion rate of potassium ion. The secretion of aldosterone is regulated by two mechanisms. First, the concentration of sodium ions secreted may be a factor since increased rates of aldosterone secretion are found when dietary sodium is severely limited. Second, reduced blood flow to the kidney stimulates certain kidney cells to secrete the proteolytic enzyme renin, which converts the inactive angiotensinogen globulin in the blood into angiotensin 1. Another enzyme then converts angiotensin I into a ngiotensin II, its active form. This peptide, in turn, stimulates the secretion of aldosterone by the adrenal cortex. Pathologically elevated aldosterone secretion with concomitant excessive retention of salt and water often results in edema. (Kumar Clark, 2002) Urea is a by-product of protein metabolism that is formed in the liver is formed by the enzymatic deamination of amino acids (urea cycle). The immediate precursor of urea is arginine, which is hydrolyzed to give urea and Ornithine. The urea is excreted by the kidneys and Ornithine in the liver combine with ammonia, formed by the catabolism of amino acids, to regenerate arginine and thereby continue the process of urea formation. The blood urea nitrogen (BUN) test measures the level of urea nitrogen in a sample of the patients blood. In healthy people, most urea nitrogen is filtered out by the kidneys and leaves the body in the urine, because urea contains ammonia, which is toxic to the body. If the patients kidneys are not functioning properly or if the body is using large amounts of protein, the BUN level will rise. If the patient has severe liver disease, the BUN will drop. High levels of BUN may indicate kidney disease or failure; blockage of the urinary tract by a kidney stone or tumour; a heart attack or congestive heart failure; dehydration; fever; shock; or bleeding in the digestive tract. High BUN levels can sometimes occur during late pregnancy or result from eating large amounts of protein-rich foods. A BUN level higher than 100 mg/dl, points to severe kidney damage. (Kumar Clark, 2002) Materials and method Please refer to medical biochemistry practical book (BMS2). Result The equation obtained from the graph used to calculate the Urea concentration of patients is: Y = 0.0238 X Where Y = absorbance X = urea concentration Patient 1 = 0.231/0.0238 = 9.7 mmol/L Patient 2 = 0.149/0.0238 = 6.3 mmol/L Patient 3 = 0.188/0.0238 = 7.89 x 10 = 78.9 mmol/L Patient 4 = 0.376/0.0238 = 7.5 mmol/L Discussion The concentration of sodium and potassium for the four patients was measured by using the flame photometer. For the estimation of urea concentration, a standard calibration curve using different standard concentrations been plotted which used to determine the test samples concentrations. In this practical, the abnormal conditions are varying for each of the patients. Addisons disease is a disorder of the adrenal cortex in which the adrenal glands are under active, resulting in a deficiency of adrenal hormones. Addisons disease can start at any age and affects males and females equally. The adrenal glands are affected by an autoimmune reaction in which the bodys immune system attacks and destroys the adrenal cortex. The glands may also be destroyed by cancer, an infection such as tuberculosis, or another identifiable disease. In infants and children, Addisons disease may be due to a genetic abnormality of the adrenal glands. The majority of the clinical features of adrenal failure are due to lack of glucocorticoid and mineralcorticoid. In Addisons disease cortisol levels are reduced which lead, through feedback, to increase corticotrophin-releasing hormone (CRH) and adrenocorticotrophic hormone (ACTH) production. When the adrenal glands become under active, they tend to produce inadequate amounts of all adrenal hormones. Thus, Addisons disease aff ects the balance of water, sodium, and potassium in the body, as well as the bodys ability to control blood pressure and react to stress. In addition, loss of androgens, such as dehydroepiandrosterone (DHEA), may cause a loss of the body hair in women. A deficiency of aldosterone in particular causes the body to excrete large amount of sodium and potassium, leading to low levels of sodium and high levels of potassium in the blood. The kidneys are not able to concentrate urine, so when a person with Addisons disease drinks too much water or loses too much sodium, the level of sodium in the blood falls. Inability to concentrate urine ultimately causes the person to urinate excessively and become dehydrated. Severe dehydration and low sodium level reduce blood volume and can culminate in shock. Dehydration also causes a high blood urea level. In Addisons disease, the pituitary gland produces more corticotrophin in an attempt to stimulate the adrenal glands. Corticotrophin also stimulat es melanin production, so dark pigmentation of the skin and the lining of the mouth often develop. People with Addisons disease are not able to produce additional corticosteroids when they are stressed. Therefore, they are susceptible to serious symptoms and complications when confronted with illness, extreme fatigue, severe injury, surgery, or possibly severe psychological stress. Secondary adrenal insufficiency is a term given to a disorder that resembles Addisons disease. In this disorder, the adrenal glands are under active because the pituitary gland is not stimulating them, not because the adrenal glands have been destroyed. Blood tests may show low sodium level and high potassium level and usually indicate that the kidneys are not working well. The cortisol level may be low and corticotrophin level may be high. However, the diagnosis is usually confirmed by measuring cortisol level after they have been stimulated with corticotrophin. If cortisol level is low, further tests are needed to determine if problem is Addisons or secondary adrenal insufficiency. Patient-1 has very low sodium 116 mmol/L (135-145 mmol/L), high potassium 6.2 mmol/L (3.6-5.0 mmol/L) and high urea 9.7 mmol/L (3.3-7.5 mmol/L). These abnormal results mostly fit Addisons disease. Sodium been lost in urine in exchange with potassium which causes depletion of Na+ in the blood and increase K+ as both cortisol and aldesterone hormones are absent. Urea level is elevated as a secondary to dehydration and could be due to renal perfusion. ACTH measurement can be used to confirm the diagnosis. Conns syndrome is known as primary aldostronism, is due to the hyper secretion of aldesterone, usually by adenoma of the adrenal cortex or loss often nodular hyperplasia. It characterised by sodium retention and potassium depletion, because plasma renin feed back mechanism is depressed. Under normal conditions aldesterone is regulated by the renin angiotensim mechanism. The principle physiological function of aldesterone is to conserve Na+ . It dose this mainly by facilitating the reabsorption of Na+ and excretion of K+ and H+ in the distal renal tubule. Aldesterone also plays a major role in regulating water and electrolytes balance and blood pressure. The renin-angiotension aldesterone system is the most important controlling mechanism, but ACTH, Na+ and K+ also affect aldesterone secretion. The release of the enzyme renin is stimulated by fall in circulating blood volume or renal perfusion pressure and loss of Na+. The enzyme stimulate the osmoreceptors in the hypothalamus which c auses the release of antidiuretic hormone (ADH) from posterior pituitary gland. ADH targets the kidneys to increase the water reabsorption and causes arterioles to constrict. Renin also acts on its substrate and splits off the inactive decapeptide angiotensim I. Then angiotenism-converting enzyme (ACE), present in lung and plasma, converts angiotensim I to the active angiotensim II which stimulates the release of aldesterone by the adrenal cortex. Aldosterone increases the retention of sodium, chloride ions and water by the kidneys. The laboratory findings include low serum potassium which is a consequence of increased renal potassium excretion, normal or slightly increased sodium in plasma due to increased reabsorption from the renal tubules. Also the renin level will be low and do not rise in response to sodium depletion as they would be in normal persons. In addition, prolonged potassium depletion and hypertension are signs of renal damage. The clinical significance of Coons disease represented with hypertension, muscular weakness and anther neurological manifestation due to loss of K+ which play role in muscles and neurons contraction. Polyuria and thirst secondary to poor renal concentration. Any patient represent hypertension with low potassium concentration should be suspected to have Coons disease. Any patient under diuretic treatment should be monitored overnight as this manifest low potassium. Patient-2 has normal urea level 6.3 mmol/L (3.3-7.5 mmol/L), sodium result is 144 mmol/L, just below the upper limit (135-145 mmol/L) and very low potassium which supports the diagnosis of Coons syndrome. The high aldosterone level in the blood acts on the kidneys to increase the loss of mineral potassium in the urine and facilitate the reabsorption of Na+. Renal failure is the inability of the kidneys to adequately filter metabolic waste products from the blood. Chronic kidney failure is a gradual decline in kidney function which may be explained in terms of a full solute load fall in on a reduced number of functionally normal nephrons. The glomerular filtration rate (GFR) is invariably reduced, associated with retention of urea, creatinine, urate and other organic substances. The kidneys are less able to control the amount and distribution of body water (fluid balance) and the levels of electrolytes (sodium, potassium, calcium, phosphate) in the blood and blood pressure often rise. The kidneys lose their ability to produce sufficient amounts of a hormone (erythropoietin) that stimulates the formation of new red blood cells, resulting in a low red blood cell count (anemia). In children, kidney failure affects the growth of bones. In both children and adults, kidney failure can lead to weaker, abnormal bones. The increased solute load per nephrons impairs the kidneys ability to reduce concentrated urine. As the GFR falls to lower levels retention of Na+ occurs but there is no consistent pattern alteration in plasma Na+ in these cases and in many the results remain normal. Potassium clearance may be increased and raised plasma K+ is uncommon in spite of the tendency for K+ to come out of cells due to the metabolic acidosis that is usually present. However, patients with renal failure are unable to excrete large loads of K+. The level of urea and creatinine will also rise as a result of decreased excretion by the kidneys. Patient-3 has a normal sodium levels 137 mmol/L with a high potassium .8.7 mmol/L and very high urea (78.9 mmol/l) levels which indicates abnormal kidney function. The patient is most probably suffering from chronic renal failure. The numbers of healthy functioning normal nephrons are reduced therefore; there will be a reduction in the execration of urea which will accumulates in the blood. Because of the low GRF, potassium blood levels are increased. The patient must undergo renal dialysis. Diabetic ketoacidosis (DKA) is a common acute complication of insulin-dependent, or type 1 diabetes mellitus (IDDM) due to insulin deficiency which is accompanied by raised plasma concentration of diabetogenic hormones (Adrenaline, Cortisol, Growth hormone and Glucagon ).Before the discovery of insulin in the 1920s, patients rarely survived diabetic ketoacidosis. This complication is still potentially lethal, with an average mortality rate between 5 and 10%. Although the risk of diabetic ketoacidosis is greatest for patients with IDDM, the condition may also occur in patients with non- insulin-dependent diabetes (NIDDM) under stressful conditions, such as during a myocardial infarction. Common symptoms are thirst due to dehydration, polyuria, nausea and weakness that have progressed over several days, which result in coma over the course of several hours. Because of the variable symptoms, diabetic ketoacidosis should be considered in any ill diabetic patient, particularly if the patient presents with nausea and vomiting. Common clinical findings include tachycardia, tachypnea, dehydration, altered mental status and a fruity breath odour, indicating the presence of ketones. Plasma glucose is normally maintained between 4.5 and 8.0mmol/1. Without insulin, most cells cannot use the sugar that is in the blood. Cells still need energy to survive, and they switch to a back-up mechanism to obtain energy. Fat cells begin to break down, producing compounds called ketones. Ketones provide some energy to cells but also make the blood too acidic (ketoacidosis). Since plasma glucose diabetic ketoacidosis exceed the renal threshold; glucose is always present in the urine of patients (glycosuria) with ketoacidosis, the pH of the blood is important in determining the severity of the condition. Blood normally has a pH of 7.35-7.45, maintained by the buffering systems, the most important of which is the bicarbonate buffer system. When acids accumulate in the blood, they dissociate with an increase in hydrogen ion concentration. Bicarbonate can usually neutralise hydrogen ions by incorporating them into water. DKA is associated with electrolyte imbalances; sodium and potassium levels in particular are affected. Serum sodium levels may be low, high or normal. When evaluating the serum sodium level, it is helpful to remember that hyperglycemia causes a shift of free water into the extracellular space, diluting the measured sodium concentration which results in lost of sodium via lie urine as a result of osmotic diuresis. In addition, vomiting, a common feature of ketoacidosis is associated with a loss of sodium from the gastrointestinal tract. This might not always be reflected in the blood results because it is a measure of concentration and, as has already been illustrated, dehydration will be present. Normal plasma sodium levels are maintained between 135 and 145mmol/l, however, despite the actual deficit, patients with DKA might display wide-ranging plasma sodium levels depending on the relative losses of water and sodium. Total body potassium is always depleted in ketoacidosis as potassium is also lost in urine and vomit. The plasma concentration of potassium, however, remains relatively high due to the passage of potassium out of the cells and into the extracellular fluid. One of the mechanisms that normally control the passage of potassium into and out of cells is the sodium/potassium pump. This pump requires intracellular glucose, which is not available in ketoacidosis, consequently, the pump cannot function and potassium leaks out of the cell and into the plasma. Furthermore, potassium is freely exchangeable with hydrogen across the cell membrane. If the hydrogen concentration is high as in DKA, hydrogen will move into the cell in exchange for potassium. So, despite an overall potassium deficit, plasma levels are usually raised in ketoacidosis, at the expense of the body cells. The kidneys can malfunction, resulting in kidney failure that may require dialysis or kidney transplantation. Doctors usu ally check the urine of people with diabetes for abnormally high levels of protein (albumin), which is an early sign of kidney damage. At the earliest sign of kidney complications, the person is often given angiotensin-converting enzyme (ACE) inhibitors, drugs that slow the progression of kidney disease by decreasing blood flow to the kidneys which prevent the kidneys from excreting normal amounts of potassium leads to mild hyperkalaemia. The result obtained for patient-4 corresponding with the clinical findings found in diabetic ketoacidosis. The sodium is reduced (130 mmol/L) and the potassium reading is relatively high (5.8 mmol/L) when compared with the normal reference range. There is a marked increase in urea (15.6 mmol/L) because as mentioned earlier the kidneys can malfunction, resulting in kidney failure that will concentrate fluid in the extracellular compartment. Conclusion Patient 1 is suffering from Addisons disease Patient 2 is suffering from Coons syndrome Patient 3 is suffering from chronic renal failure Patient 4 is suffering from diabetic ketoacidos Questions Calculate the osmolarity (mmol/L) for each patient. Why would patients3s (the diabetic) osmolarity be underestimate? Osmolarity is a property of particles of solute per liter of solution. If a substance can dissociate in solution, it may contribute more than one equivalent to the osmolarity of the solution. The expected osmolarity of plasma can be calculated according to the following formula. Calculated osmolarity (mOsm/kg) = 2*[Na +] + 2*[K+] + (glucose) + (urea) Patient 1 = 2 x 116 + 2 x 6.2 + [glucose] + 9.7 Patient 2 = 2 x 144 + 2 x 2.8 + [glucose] + 6.3 Patient 3 = 2 x 137 + 2 x 8.7 + [glucose] + 78.9 Patient 4 = 2 x 130 + 2 x 5.8 + [glucose] + 15.7 The final result is not obtained as the glucose values are not given, so the calculation can not be done without glucose values. The patient 3 (the diabetic) osmolarity is underestimated because of insulin deficiency, the cells uptake of glucose, which causes hyperglycaemia. What is the abnormality in the clinical condition Diabetes Insipidus, and how does it affect water electrolyte balance? Many different hormones help to control metabolic activities within the body. One of these is called anti-diuretic hormone (ADH) and its function is to help control the balance of water in the body. It does this by regulating the production of urine. ADH is produced by the hypothalamus and then stored in the pituitary gland until it is needed. Diabetes Insipidus usually results from the decreased production of antidiuretic hormone. Alternatively, the disorder may be caused by failure of the pituitary gland to release Antidiuretic hormone into the bloodstream. Other causes of diabetes Insipidus include damage done during surgery on the hypothalamus or pituitary gland; a brain injury, particularly a fracture of the base of the skull; a tumor; sarcoidosis or tuberculosis; an aneurysm (a bulge in the wall of an artery) or blockage in the arteries leading to the brain; some forms of encephalitis or meningitis; and the rare disease Langerhans cell granulomatosis (histiocytosis X). Another type of diabetes Insipidus, nephrogenic diabetes Insipidus, may be caused by abnormalities in the kidneys. Diabetes Insipidus suspected in people who produce large amounts of urine. They first test the urine for sugar to rule out diabetes mellitus. Blood tests show abnormal levels of many electrolytes, including a high level of sodium. The best test is a water deprivation test, in which urine production, blood electrolyte (sodium) levels, and weight are measured regularly for a period of about 12 hours, during which the person is not allowed to drink. A doctor monitors the persons condition throughout the course of the test. At the end of the 12 hours, or sooner if the persons blood pressure falls or heart rate increases or if he loses more than 5% of his body weight, the doctor stops the test and injects Antidiuretic hormone. The diagnosis of central diabetes Insipidus is confirmed if, in response to Antidiuretic hormone, the persons excessive urination stops, the urine becomes mor e concentrated, the blood pressure rises, and the heart beats more normally. The diagnosis of nephrogenic diabetes Insipidus is made if, after the injection, the excessive urination continues, the urine remains dilute, and blood pressure and heart rate do not change. How do diuretics work? And what are the three main groups of diuretics? Diuretics work in the kidneys to increase the elimination of water and electrolytes, thereby causing more urine to form. Because the amount of fluid in the body is lowered, blood pressure goes down, too. Different chemical types work in different areas of the nephrons; so many different classes of diuretics are used. Three of the most common classes of diuretics are: Thiazide and Thiazide-Like Diuretics Drugs containing the chemical Thiazide and similar chemicals like indapamide and metolazone are suggested as the first drugs to try for most people with high blood pressure. They affect the distal convoluted tubule, where large amounts of sodium and water are absorbed back into the body. By blocking the re-absorption process, these drugs force more sodium and more water into the urine to be removed from the body. Thiazides may also relax the muscles in blood vessel walls, making blood flow more easily. Loop Diuretics More powerful than the Thiazide are classes of diuretics that work in the area of the Loop of Henle. These loop diuretics mainly interfere with the bodys re-absorption of chloride, but they also keep sodium from re-entering the blood. Unfortunately, loop diuretics are also more likely to promote the elimination of calcium, magnesium and especially potassium. Shortages of any of these essential electrolytes can cause serious problems such as irregular heartbeats. Potassium-Sparing Diuretics The third common group of diuretics consists of drugs that are much weaker than the Thiazides or the loop diuretics but potassium-sparing diuretics do not reduce potassium levels nearly as much as other kinds of diuretics do. They inhibit aldosterone and/or block sodium reabsorption and inhibit potassium excretion in the distal tubule. Sodium, Potassium and Urea Measurement Sodium, Potassium and Urea Measurement Introduction Electrolytes are solutions that conduct electricity. Any molecule that becomes an ion when mixed with water is an electrolyte. Salts such as sodium, potassium, calcium and chloride are examples of electrolytes. When these molecules dissolve in water, they release ions with an electric charge, positive or negative, that attracts or repels other ions during a chemical reaction. In living cells, most chemical reaction occur in an aqueous environment since approximately 75% of the mass of the living cell is water. Normally 70kg man, represent with 42 litres of total body water that contribute for about 60% of the total body weight. (Marshall, 2000). 66% of this water is in the intracellular fluid (ICF) and 33% in the extracellular fluid (ECF). The principle univalent cations in the ECF and ICF are sodium (Na+) and potassium (K+) respectively. Sodium (Na+) Sodium is the major cation of the extracellular fluid (ECF). It represents almost one-half the osmatic strength of plasma. It plays an important role in maintaining the normal distribution of water and osmatic pressure in the ECF compartment. Sodium levels in the body are regulated ultimately by the kidneys (it excrete excess sodium). The main source of sodium is sodium chloride (NaCl- table salt) which is used in cooking. The daily requirement of the body is about 1 2 mmol/day. Sodium is filtered freely by the glomeruli. About 70 80 % of the filtered sodium load is reabsorbed actively in the proximal tubules (with chloride and water passively) and anther 20 25 % is reabsorbed in the loop of Henle (along with chloride and more water). Normal ECF sodium concentration is 135 145 mmol/L while that of the intracellular fluid (ICF) is only 4-10 mmol/L. sodium is lost via urine, sweat or stool. (Marshall, 2000). Hypernatraemia Hypernatraemia (high sodium levels in the blood) may occurs due to increase sodium intake, decrease excretion, dehydration (water loss) or failure to replace normal water losses. It can also occurs because of excessive mineral corticoid (such as Aldosterone) production acting on renal reabsorption. The clinical features of hypernatraemia are non-specific or masked by underlying conditions. Nausea, vomiting, fever and confusion may occur. A history of long standing polyuria, polydipsia, and theist indicates diabetes insipidus. Hypernatraemia is caused by many diseases such as renal failure, Cushings syndrome or Conns syndrome. Conns syndrome is a disease of the adrenal glands involving excess production of a hormone, called aldosterone. Another name for the condition is primary hyperaldosteronism. Hyponatraemia Hyponatraemia (low sodium levels in the blood) is caused by impaired renal reabsorption of sodium. This occurs in Addisons disease of the adrenal gland due to loss of aldosterone producing zona glomerulosa cortical cells. Sodium decreases in severe sweating in a hot climate or during physical exertion such as marathon running. Falsely low serum sodium concentration may be found in hyperlipidaemic states where the sodium concentration in the aqueous phase of the serum is actually normal, but the lipid contributes to the total volume of serum measured. The symptoms are non-specific and include headache, confusion and restlessness. Hyponatraemia is seen in Addisons disease and/or excessive diuretic therapy. (Kumar Clark, 2002) Potassium (K+) It is the major intracellular cation. It is average concentration in tissue cells is 150mmol/L and in RBCs is 105 mmol/L. The body requirement for K+ is satisfied by a dietary intake. K+ is absorbed by the gastrointestinal tract and distributed rapidly, with a small amount taken up by cells and most excreted by the kidneys. Potassium which filtered by the glomeruli is reabsorbed almost completely in the proximal tubules (PT) and then secreted in the distal tubules (DT) in exchange for sodium under the influence of aldosterone. Factors that regulate distal tubular secretion of potassium include intake of sodium and potassium, water flow rate in distal tubules, plasma level of mineralocorticoids, and acid-base balance. Renal tubular acidosis, as well as metabolic and respiratory acidosis and alkalosis also affect renal regulation of potassium excretion. (Kumar Clark, 2002). Hyperkalaemia Hyperkalaemia is high K+ levels in the blood. Potassium is in high concentration within cells than in extracellular fluids. This means that relatively small changes in plasma concentration can underestimate possibly larger changes in intracellular concentrations. In addition, extensive tissue necrosis can liberate large amounts of potassium into the plasma causing the concentration to reach dangerously high levels. The commonest cause of hyperkalaemia is kidney failure causing decreased urinary potassium excretion. Severe hyperkalaemia (> 6.5 mmol/l) is a serious medical emergency needs treatment as fast as possible because of the risk of developing cardiac arrest. Moderate hyperkalaemia is relatively asymptomatic emphasising the importance of regular biochemical monitoring to avoid sudden fatal complications Hypokalaemia Hypokalaemia (low potassium levels in the blood) has many causes; the most common are diuretic treatment (particularly thiazides), hyperaldosteronism and renal disease. Hypokalaemia is often associated with a metabolic alkalosis due to hydrogen ion shift into the intracellular compartment. Clinically, it presents with paralysis, muscular weakness and cardiac dysrhythmais. (Kumar Clark, 2002) Aldosterone Aldosterone is a steroidal hormone secreted by the adrenal cortex. It is the hormone that regulates the bodys electrolyte balance. This hormone synthesized exclusively in the zona glomerulosa region of the adrenal cortex. This zona contains 18-hydroxysteroid dehydrogenase enzyme which a requisite enzyme for the formation of Aldosterone. Aldosterone acts directly on the kidney tubules to decrease the secretion rate of sodium ion (with accompanying retention of water), and to increase the excretion rate of potassium ion. The secretion of aldosterone is regulated by two mechanisms. First, the concentration of sodium ions secreted may be a factor since increased rates of aldosterone secretion are found when dietary sodium is severely limited. Second, reduced blood flow to the kidney stimulates certain kidney cells to secrete the proteolytic enzyme renin, which converts the inactive angiotensinogen globulin in the blood into angiotensin 1. Another enzyme then converts angiotensin I into a ngiotensin II, its active form. This peptide, in turn, stimulates the secretion of aldosterone by the adrenal cortex. Pathologically elevated aldosterone secretion with concomitant excessive retention of salt and water often results in edema. (Kumar Clark, 2002) Urea is a by-product of protein metabolism that is formed in the liver is formed by the enzymatic deamination of amino acids (urea cycle). The immediate precursor of urea is arginine, which is hydrolyzed to give urea and Ornithine. The urea is excreted by the kidneys and Ornithine in the liver combine with ammonia, formed by the catabolism of amino acids, to regenerate arginine and thereby continue the process of urea formation. The blood urea nitrogen (BUN) test measures the level of urea nitrogen in a sample of the patients blood. In healthy people, most urea nitrogen is filtered out by the kidneys and leaves the body in the urine, because urea contains ammonia, which is toxic to the body. If the patients kidneys are not functioning properly or if the body is using large amounts of protein, the BUN level will rise. If the patient has severe liver disease, the BUN will drop. High levels of BUN may indicate kidney disease or failure; blockage of the urinary tract by a kidney stone or tumour; a heart attack or congestive heart failure; dehydration; fever; shock; or bleeding in the digestive tract. High BUN levels can sometimes occur during late pregnancy or result from eating large amounts of protein-rich foods. A BUN level higher than 100 mg/dl, points to severe kidney damage. (Kumar Clark, 2002) Materials and method Please refer to medical biochemistry practical book (BMS2). Result The equation obtained from the graph used to calculate the Urea concentration of patients is: Y = 0.0238 X Where Y = absorbance X = urea concentration Patient 1 = 0.231/0.0238 = 9.7 mmol/L Patient 2 = 0.149/0.0238 = 6.3 mmol/L Patient 3 = 0.188/0.0238 = 7.89 x 10 = 78.9 mmol/L Patient 4 = 0.376/0.0238 = 7.5 mmol/L Discussion The concentration of sodium and potassium for the four patients was measured by using the flame photometer. For the estimation of urea concentration, a standard calibration curve using different standard concentrations been plotted which used to determine the test samples concentrations. In this practical, the abnormal conditions are varying for each of the patients. Addisons disease is a disorder of the adrenal cortex in which the adrenal glands are under active, resulting in a deficiency of adrenal hormones. Addisons disease can start at any age and affects males and females equally. The adrenal glands are affected by an autoimmune reaction in which the bodys immune system attacks and destroys the adrenal cortex. The glands may also be destroyed by cancer, an infection such as tuberculosis, or another identifiable disease. In infants and children, Addisons disease may be due to a genetic abnormality of the adrenal glands. The majority of the clinical features of adrenal failure are due to lack of glucocorticoid and mineralcorticoid. In Addisons disease cortisol levels are reduced which lead, through feedback, to increase corticotrophin-releasing hormone (CRH) and adrenocorticotrophic hormone (ACTH) production. When the adrenal glands become under active, they tend to produce inadequate amounts of all adrenal hormones. Thus, Addisons disease aff ects the balance of water, sodium, and potassium in the body, as well as the bodys ability to control blood pressure and react to stress. In addition, loss of androgens, such as dehydroepiandrosterone (DHEA), may cause a loss of the body hair in women. A deficiency of aldosterone in particular causes the body to excrete large amount of sodium and potassium, leading to low levels of sodium and high levels of potassium in the blood. The kidneys are not able to concentrate urine, so when a person with Addisons disease drinks too much water or loses too much sodium, the level of sodium in the blood falls. Inability to concentrate urine ultimately causes the person to urinate excessively and become dehydrated. Severe dehydration and low sodium level reduce blood volume and can culminate in shock. Dehydration also causes a high blood urea level. In Addisons disease, the pituitary gland produces more corticotrophin in an attempt to stimulate the adrenal glands. Corticotrophin also stimulat es melanin production, so dark pigmentation of the skin and the lining of the mouth often develop. People with Addisons disease are not able to produce additional corticosteroids when they are stressed. Therefore, they are susceptible to serious symptoms and complications when confronted with illness, extreme fatigue, severe injury, surgery, or possibly severe psychological stress. Secondary adrenal insufficiency is a term given to a disorder that resembles Addisons disease. In this disorder, the adrenal glands are under active because the pituitary gland is not stimulating them, not because the adrenal glands have been destroyed. Blood tests may show low sodium level and high potassium level and usually indicate that the kidneys are not working well. The cortisol level may be low and corticotrophin level may be high. However, the diagnosis is usually confirmed by measuring cortisol level after they have been stimulated with corticotrophin. If cortisol level is low, further tests are needed to determine if problem is Addisons or secondary adrenal insufficiency. Patient-1 has very low sodium 116 mmol/L (135-145 mmol/L), high potassium 6.2 mmol/L (3.6-5.0 mmol/L) and high urea 9.7 mmol/L (3.3-7.5 mmol/L). These abnormal results mostly fit Addisons disease. Sodium been lost in urine in exchange with potassium which causes depletion of Na+ in the blood and increase K+ as both cortisol and aldesterone hormones are absent. Urea level is elevated as a secondary to dehydration and could be due to renal perfusion. ACTH measurement can be used to confirm the diagnosis. Conns syndrome is known as primary aldostronism, is due to the hyper secretion of aldesterone, usually by adenoma of the adrenal cortex or loss often nodular hyperplasia. It characterised by sodium retention and potassium depletion, because plasma renin feed back mechanism is depressed. Under normal conditions aldesterone is regulated by the renin angiotensim mechanism. The principle physiological function of aldesterone is to conserve Na+ . It dose this mainly by facilitating the reabsorption of Na+ and excretion of K+ and H+ in the distal renal tubule. Aldesterone also plays a major role in regulating water and electrolytes balance and blood pressure. The renin-angiotension aldesterone system is the most important controlling mechanism, but ACTH, Na+ and K+ also affect aldesterone secretion. The release of the enzyme renin is stimulated by fall in circulating blood volume or renal perfusion pressure and loss of Na+. The enzyme stimulate the osmoreceptors in the hypothalamus which c auses the release of antidiuretic hormone (ADH) from posterior pituitary gland. ADH targets the kidneys to increase the water reabsorption and causes arterioles to constrict. Renin also acts on its substrate and splits off the inactive decapeptide angiotensim I. Then angiotenism-converting enzyme (ACE), present in lung and plasma, converts angiotensim I to the active angiotensim II which stimulates the release of aldesterone by the adrenal cortex. Aldosterone increases the retention of sodium, chloride ions and water by the kidneys. The laboratory findings include low serum potassium which is a consequence of increased renal potassium excretion, normal or slightly increased sodium in plasma due to increased reabsorption from the renal tubules. Also the renin level will be low and do not rise in response to sodium depletion as they would be in normal persons. In addition, prolonged potassium depletion and hypertension are signs of renal damage. The clinical significance of Coons disease represented with hypertension, muscular weakness and anther neurological manifestation due to loss of K+ which play role in muscles and neurons contraction. Polyuria and thirst secondary to poor renal concentration. Any patient represent hypertension with low potassium concentration should be suspected to have Coons disease. Any patient under diuretic treatment should be monitored overnight as this manifest low potassium. Patient-2 has normal urea level 6.3 mmol/L (3.3-7.5 mmol/L), sodium result is 144 mmol/L, just below the upper limit (135-145 mmol/L) and very low potassium which supports the diagnosis of Coons syndrome. The high aldosterone level in the blood acts on the kidneys to increase the loss of mineral potassium in the urine and facilitate the reabsorption of Na+. Renal failure is the inability of the kidneys to adequately filter metabolic waste products from the blood. Chronic kidney failure is a gradual decline in kidney function which may be explained in terms of a full solute load fall in on a reduced number of functionally normal nephrons. The glomerular filtration rate (GFR) is invariably reduced, associated with retention of urea, creatinine, urate and other organic substances. The kidneys are less able to control the amount and distribution of body water (fluid balance) and the levels of electrolytes (sodium, potassium, calcium, phosphate) in the blood and blood pressure often rise. The kidneys lose their ability to produce sufficient amounts of a hormone (erythropoietin) that stimulates the formation of new red blood cells, resulting in a low red blood cell count (anemia). In children, kidney failure affects the growth of bones. In both children and adults, kidney failure can lead to weaker, abnormal bones. The increased solute load per nephrons impairs the kidneys ability to reduce concentrated urine. As the GFR falls to lower levels retention of Na+ occurs but there is no consistent pattern alteration in plasma Na+ in these cases and in many the results remain normal. Potassium clearance may be increased and raised plasma K+ is uncommon in spite of the tendency for K+ to come out of cells due to the metabolic acidosis that is usually present. However, patients with renal failure are unable to excrete large loads of K+. The level of urea and creatinine will also rise as a result of decreased excretion by the kidneys. Patient-3 has a normal sodium levels 137 mmol/L with a high potassium .8.7 mmol/L and very high urea (78.9 mmol/l) levels which indicates abnormal kidney function. The patient is most probably suffering from chronic renal failure. The numbers of healthy functioning normal nephrons are reduced therefore; there will be a reduction in the execration of urea which will accumulates in the blood. Because of the low GRF, potassium blood levels are increased. The patient must undergo renal dialysis. Diabetic ketoacidosis (DKA) is a common acute complication of insulin-dependent, or type 1 diabetes mellitus (IDDM) due to insulin deficiency which is accompanied by raised plasma concentration of diabetogenic hormones (Adrenaline, Cortisol, Growth hormone and Glucagon ).Before the discovery of insulin in the 1920s, patients rarely survived diabetic ketoacidosis. This complication is still potentially lethal, with an average mortality rate between 5 and 10%. Although the risk of diabetic ketoacidosis is greatest for patients with IDDM, the condition may also occur in patients with non- insulin-dependent diabetes (NIDDM) under stressful conditions, such as during a myocardial infarction. Common symptoms are thirst due to dehydration, polyuria, nausea and weakness that have progressed over several days, which result in coma over the course of several hours. Because of the variable symptoms, diabetic ketoacidosis should be considered in any ill diabetic patient, particularly if the patient presents with nausea and vomiting. Common clinical findings include tachycardia, tachypnea, dehydration, altered mental status and a fruity breath odour, indicating the presence of ketones. Plasma glucose is normally maintained between 4.5 and 8.0mmol/1. Without insulin, most cells cannot use the sugar that is in the blood. Cells still need energy to survive, and they switch to a back-up mechanism to obtain energy. Fat cells begin to break down, producing compounds called ketones. Ketones provide some energy to cells but also make the blood too acidic (ketoacidosis). Since plasma glucose diabetic ketoacidosis exceed the renal threshold; glucose is always present in the urine of patients (glycosuria) with ketoacidosis, the pH of the blood is important in determining the severity of the condition. Blood normally has a pH of 7.35-7.45, maintained by the buffering systems, the most important of which is the bicarbonate buffer system. When acids accumulate in the blood, they dissociate with an increase in hydrogen ion concentration. Bicarbonate can usually neutralise hydrogen ions by incorporating them into water. DKA is associated with electrolyte imbalances; sodium and potassium levels in particular are affected. Serum sodium levels may be low, high or normal. When evaluating the serum sodium level, it is helpful to remember that hyperglycemia causes a shift of free water into the extracellular space, diluting the measured sodium concentration which results in lost of sodium via lie urine as a result of osmotic diuresis. In addition, vomiting, a common feature of ketoacidosis is associated with a loss of sodium from the gastrointestinal tract. This might not always be reflected in the blood results because it is a measure of concentration and, as has already been illustrated, dehydration will be present. Normal plasma sodium levels are maintained between 135 and 145mmol/l, however, despite the actual deficit, patients with DKA might display wide-ranging plasma sodium levels depending on the relative losses of water and sodium. Total body potassium is always depleted in ketoacidosis as potassium is also lost in urine and vomit. The plasma concentration of potassium, however, remains relatively high due to the passage of potassium out of the cells and into the extracellular fluid. One of the mechanisms that normally control the passage of potassium into and out of cells is the sodium/potassium pump. This pump requires intracellular glucose, which is not available in ketoacidosis, consequently, the pump cannot function and potassium leaks out of the cell and into the plasma. Furthermore, potassium is freely exchangeable with hydrogen across the cell membrane. If the hydrogen concentration is high as in DKA, hydrogen will move into the cell in exchange for potassium. So, despite an overall potassium deficit, plasma levels are usually raised in ketoacidosis, at the expense of the body cells. The kidneys can malfunction, resulting in kidney failure that may require dialysis or kidney transplantation. Doctors usu ally check the urine of people with diabetes for abnormally high levels of protein (albumin), which is an early sign of kidney damage. At the earliest sign of kidney complications, the person is often given angiotensin-converting enzyme (ACE) inhibitors, drugs that slow the progression of kidney disease by decreasing blood flow to the kidneys which prevent the kidneys from excreting normal amounts of potassium leads to mild hyperkalaemia. The result obtained for patient-4 corresponding with the clinical findings found in diabetic ketoacidosis. The sodium is reduced (130 mmol/L) and the potassium reading is relatively high (5.8 mmol/L) when compared with the normal reference range. There is a marked increase in urea (15.6 mmol/L) because as mentioned earlier the kidneys can malfunction, resulting in kidney failure that will concentrate fluid in the extracellular compartment. Conclusion Patient 1 is suffering from Addisons disease Patient 2 is suffering from Coons syndrome Patient 3 is suffering from chronic renal failure Patient 4 is suffering from diabetic ketoacidos Questions Calculate the osmolarity (mmol/L) for each patient. Why would patients3s (the diabetic) osmolarity be underestimate? Osmolarity is a property of particles of solute per liter of solution. If a substance can dissociate in solution, it may contribute more than one equivalent to the osmolarity of the solution. The expected osmolarity of plasma can be calculated according to the following formula. Calculated osmolarity (mOsm/kg) = 2*[Na +] + 2*[K+] + (glucose) + (urea) Patient 1 = 2 x 116 + 2 x 6.2 + [glucose] + 9.7 Patient 2 = 2 x 144 + 2 x 2.8 + [glucose] + 6.3 Patient 3 = 2 x 137 + 2 x 8.7 + [glucose] + 78.9 Patient 4 = 2 x 130 + 2 x 5.8 + [glucose] + 15.7 The final result is not obtained as the glucose values are not given, so the calculation can not be done without glucose values. The patient 3 (the diabetic) osmolarity is underestimated because of insulin deficiency, the cells uptake of glucose, which causes hyperglycaemia. What is the abnormality in the clinical condition Diabetes Insipidus, and how does it affect water electrolyte balance? Many different hormones help to control metabolic activities within the body. One of these is called anti-diuretic hormone (ADH) and its function is to help control the balance of water in the body. It does this by regulating the production of urine. ADH is produced by the hypothalamus and then stored in the pituitary gland until it is needed. Diabetes Insipidus usually results from the decreased production of antidiuretic hormone. Alternatively, the disorder may be caused by failure of the pituitary gland to release Antidiuretic hormone into the bloodstream. Other causes of diabetes Insipidus include damage done during surgery on the hypothalamus or pituitary gland; a brain injury, particularly a fracture of the base of the skull; a tumor; sarcoidosis or tuberculosis; an aneurysm (a bulge in the wall of an artery) or blockage in the arteries leading to the brain; some forms of encephalitis or meningitis; and the rare disease Langerhans cell granulomatosis (histiocytosis X). Another type of diabetes Insipidus, nephrogenic diabetes Insipidus, may be caused by abnormalities in the kidneys. Diabetes Insipidus suspected in people who produce large amounts of urine. They first test the urine for sugar to rule out diabetes mellitus. Blood tests show abnormal levels of many electrolytes, including a high level of sodium. The best test is a water deprivation test, in which urine production, blood electrolyte (sodium) levels, and weight are measured regularly for a period of about 12 hours, during which the person is not allowed to drink. A doctor monitors the persons condition throughout the course of the test. At the end of the 12 hours, or sooner if the persons blood pressure falls or heart rate increases or if he loses more than 5% of his body weight, the doctor stops the test and injects Antidiuretic hormone. The diagnosis of central diabetes Insipidus is confirmed if, in response to Antidiuretic hormone, the persons excessive urination stops, the urine becomes mor e concentrated, the blood pressure rises, and the heart beats more normally. The diagnosis of nephrogenic diabetes Insipidus is made if, after the injection, the excessive urination continues, the urine remains dilute, and blood pressure and heart rate do not change. How do diuretics work? And what are the three main groups of diuretics? Diuretics work in the kidneys to increase the elimination of water and electrolytes, thereby causing more urine to form. Because the amount of fluid in the body is lowered, blood pressure goes down, too. Different chemical types work in different areas of the nephrons; so many different classes of diuretics are used. Three of the most common classes of diuretics are: Thiazide and Thiazide-Like Diuretics Drugs containing the chemical Thiazide and similar chemicals like indapamide and metolazone are suggested as the first drugs to try for most people with high blood pressure. They affect the distal convoluted tubule, where large amounts of sodium and water are absorbed back into the body. By blocking the re-absorption process, these drugs force more sodium and more water into the urine to be removed from the body. Thiazides may also relax the muscles in blood vessel walls, making blood flow more easily. Loop Diuretics More powerful than the Thiazide are classes of diuretics that work in the area of the Loop of Henle. These loop diuretics mainly interfere with the bodys re-absorption of chloride, but they also keep sodium from re-entering the blood. Unfortunately, loop diuretics are also more likely to promote the elimination of calcium, magnesium and especially potassium. Shortages of any of these essential electrolytes can cause serious problems such as irregular heartbeats. Potassium-Sparing Diuretics The third common group of diuretics consists of drugs that are much weaker than the Thiazides or the loop diuretics but potassium-sparing diuretics do not reduce potassium levels nearly as much as other kinds of diuretics do. They inhibit aldosterone and/or block sodium reabsorption and inhibit potassium excretion in the distal tubule.