7 Separate annotated bibligraphy Essay Example | Topics and Well Written Essays - 1500 words

7 Separate annotated bibligraphy - Essay Example Globalization, Dirlik argues, is not simply global integration, as suggested by its economistic ideologues and interpreters, but a new mode of fragmentation and of comprehending the world. It is therefore necessary to critically consider the historical relationship between globalization as a new beginning in breaking down old hegemonies and as the ultimate victory of capitalist modernity. He concludes that whilst globalization is best understood historically, it also has produced new ways of looking at history, and that there is a need to write world history in non-Eurocentric ways and to understand globalization from two different historical perspectives. Ikenberry shows the linked history, present, and future questions between American hegemony and open economic markets characteristic of globalization. Whilst this is not surprising since â€Å"economic relationships always bear the imprint of powerful states†, what is admirable is how America successfully utilised its political and economic interests and the tools – building institutions, managing monetary policy, and forging security alliances – to open the world economy. Ikenberry attributes hegemonic success to political and economic leadership that allowed America to resist temptations of protectionism, colonialism and isolationism. Global domination and leadership, by allowing America’s political-economic partners to prosper, assured security and economic prosperity despite distractions of domestic politics and international security. This strategic interdependence amongst America’s allies, in Europe and Japan, led to winning the Cold War. In answer, Ikenberry proposes two questions: first, how important is stable and non-competitive great power relations; and second, America’s willingness, as the world’s only superpower, to underwrite global

A proposal for company market expansion scheduled for completion by Research Paper

A proposal for company market expansion scheduled for completion by 2023 - Research Paper Example It is an American company with its headquarters in Stamford. The company offers both hotel and leisure services. Some of the properties owned by the company include spas, resorts, vacation properties and hotels. More over, the corporation owns and operates franchises (Great Britain & British Oversees Trade Board, 2004). Background information of the Starwood Hotel and Resorts Starwood Hotel is an effusive incorporated owner, worker and franchisor of hotels. The company was initially established by the real estate investment firm called Starwood Capital. The intention of the formation was to take advantage of the tax break. Frits Van Paasschen is the current CEO. The Starwood Hotel and Resort Company have a chain of brands spread across the globe. They include Westin, Sheraton, W Hotels, St. Regis, Le Meridien, Aloft and Element. The company has over 1,134 properties in over 100 nations (Gibler, Gibler, & Anderson, 2010). Moreover, it has a global employee capacity of 154,000. Starwoo d enjoys massive marketing and customer retention through its program â€Å"Starwood Preferred Guest†. The program allows members to redeem points for services offered such as room stay and flights. It is imperative to note that the luxury hotels and resorts incorporated in the Starwood Company offer unique and authentic experiences that evoke lasting memories. Moreover, for any global voyager, the collection offers an entrance to the world’s most exhilarating and attractive destinations (Gibler, Gibler, & Anderson, 2010). The luxury hotels and resorts have exceptional and cherished appearance of the location, native charms and treasures. Starwood hotels and Resort Company embrace cultural diversity. This is the sole reason as to why it has extensively established across the globe. The company sustains an associate and clientele base as diverse as the globe’s population. The diverse brands spread all over the world give Starwood a distinctive cultural identity w hich accommodates diversity. This trend of operation embraced by the company’s management as created distinctive appeal in the global market. It is factual that, expanding the operations of the company to the United Arab Emirates may not be faced by cultural based complication (Hudson, 2010). This practice has enhanced the company’s objective of inclusion of people of all races with diverse political, economic and social backgrounds. Indeed, the culture of diversity in Starwood Hotels & Resorts, Inc. is further enhanced by unique blending and mining of the associates’ talents from across the globe. The top management commitment to ensure cultural diversity is enhanced in a shared responsibility with the chain of associates spread globally. According to the company’s interests, the Starwood intends to reduce the socio-cultural gap among the employees drawn from across the globe. This kind of integration satisfies the company’s values of internationa l cooperation and amalgamation (Hudson, 2010). This practice remains the key motivation to the success of the numerous centers of the company located all over the globe. Literature review The new market in the United Arab Emirates The extent and enormity of how much the UAE has developed in nature, predominantly in the last decade, is exemplary, even beyond the international standards. This tremendous expansion in political, social and economic areas has put the UAE in the

Support Programs for Youth Transitioning Out of Foster Care Research Paper

Support Programs for Youth Transitioning Out of Foster Care - Research Paper Example According to the research the foster care system is designed to provide temporary homes and family support for children in crisis or children who do not have parents of their own. A number of options exist for children in foster care: some are adopted by their foster families, some find permanent homes with extended family, and others are adopted by individuals or families outside the system. According to McCoy-Roth, Freundlich and Ross, federal statistics reveal that as of 2007 roughly 85 percent of all children discharged from foster care did so as a result of one of these three occurrences. However, the 15 percent not reflected by this data spend their entire childhood and youth in the foster care system, until they officially grow out of the system when they reach the age of 18. Commonly, this phenomenon is referred to as â€Å"aging out of the system†. Youth that age out of the foster system often struggle with the transition from foster care to independent living; many f eel isolated, overwhelmed, and ill-equipped for life on their own. Others lack significant and supportive relationships with adults or mentors. According to Courtney, Dworsky, Lee and Raap, the authors of the longitudinal study Midwest Evaluation of the Adult Functioning of Former Foster Youth: Outcomes at Ages 23 and 24, the propensity for drug and alcohol abuse, criminal activity, unemployment, homelessness and economic marginalization remains high among these youth. (p. 5). This policy brief focuses on the experience of youth aging out of the foster care system in California. The brief is intended for state level legislators in the departments of child welfare and social services (Bardach, 2009; Moore, 1995). This brief provides some recommendations as to how to accelerate the implementation phase of the California Fostering Connections to Success Act, commonly known as Assembly Bill 12 or AB 12, which increases the age at which youth officially leave the system from 18 to 21 (Ca lifornia Fostering Connections to Success, 2012; California Implementation News, 2012; Lemley, Raucher, & Fried, 2012). I. Introduction The purpose of this policy brief is to discuss the difficulties faced by youth aging out of the foster care system in California at the age of 18, and to provide support and recommendations for the California Fostering Connections to Success Act, as well as extending foster care beyond the age of 18 in the state of California (California Fostering Connections to Success, 2012; California Implementation News, 2012; Lemley, Raucher, & Fried, 2012). Extending foster care from the age of 18 to 21 represents a viable alternative to the current practice of releasing youth from the system at age 18 (California Fostering Connections to Success, 2012; California Implementation News, 2012; Lemley, Raucher, & Fried, 2012). This policy brief argues that the decision to age youth out at 18 is premature from a developmental standpoint and essentially flushes thes e youth into a situation that they are not developmentally equipped to navigate. The policy brief is broken down into several subsections which illustrate the need for foster care to be extended beyond the age of 18 to 21. These include the Transitional Housing Placement Plus Program (THP-Plus), the THP-Plus Statewide Implementation Project, the Increasing Adoptions Act of 2008, and the California Fostering Connections to Success Act or Assembly Bill 12. The brief outlines some clear and actionable recommendations f

A proposal for company market expansion scheduled for completion by Research Paper

A proposal for company market expansion scheduled for completion by 2023 - Research Paper Example It is an American company with its headquarters in Stamford. The company offers both hotel and leisure services. Some of the properties owned by the company include spas, resorts, vacation properties and hotels. More over, the corporation owns and operates franchises (Great Britain & British Oversees Trade Board, 2004). Background information of the Starwood Hotel and Resorts Starwood Hotel is an effusive incorporated owner, worker and franchisor of hotels. The company was initially established by the real estate investment firm called Starwood Capital. The intention of the formation was to take advantage of the tax break. Frits Van Paasschen is the current CEO. The Starwood Hotel and Resort Company have a chain of brands spread across the globe. They include Westin, Sheraton, W Hotels, St. Regis, Le Meridien, Aloft and Element. The company has over 1,134 properties in over 100 nations (Gibler, Gibler, & Anderson, 2010). Moreover, it has a global employee capacity of 154,000. Starwoo d enjoys massive marketing and customer retention through its program â€Å"Starwood Preferred Guest†. The program allows members to redeem points for services offered such as room stay and flights. It is imperative to note that the luxury hotels and resorts incorporated in the Starwood Company offer unique and authentic experiences that evoke lasting memories. Moreover, for any global voyager, the collection offers an entrance to the world’s most exhilarating and attractive destinations (Gibler, Gibler, & Anderson, 2010). The luxury hotels and resorts have exceptional and cherished appearance of the location, native charms and treasures. Starwood hotels and Resort Company embrace cultural diversity. This is the sole reason as to why it has extensively established across the globe. The company sustains an associate and clientele base as diverse as the globe’s population. The diverse brands spread all over the world give Starwood a distinctive cultural identity w hich accommodates diversity. This trend of operation embraced by the company’s management as created distinctive appeal in the global market. It is factual that, expanding the operations of the company to the United Arab Emirates may not be faced by cultural based complication (Hudson, 2010). This practice has enhanced the company’s objective of inclusion of people of all races with diverse political, economic and social backgrounds. Indeed, the culture of diversity in Starwood Hotels & Resorts, Inc. is further enhanced by unique blending and mining of the associates’ talents from across the globe. The top management commitment to ensure cultural diversity is enhanced in a shared responsibility with the chain of associates spread globally. According to the company’s interests, the Starwood intends to reduce the socio-cultural gap among the employees drawn from across the globe. This kind of integration satisfies the company’s values of internationa l cooperation and amalgamation (Hudson, 2010). This practice remains the key motivation to the success of the numerous centers of the company located all over the globe. Literature review The new market in the United Arab Emirates The extent and enormity of how much the UAE has developed in nature, predominantly in the last decade, is exemplary, even beyond the international standards. This tremendous expansion in political, social and economic areas has put the UAE in the

Utilitarian and Kantain Ethics Essay Example | Topics and Well Written Essays - 250 words - 1

Utilitarian and Kantain Ethics - Essay Example Most humans act in a certain manner for their self-preservation and interests. Once an individual acknowledges and comprehends the fact that society as whole benefits and perishes more rather than own self-interests; chaos is eliminated and harmony is achieved. Utilitarianism theories are excellent in moral dilemmas as it enhances the scope of cases that it can manage. One can question this dogmatic approach to this theory. One cannot deny that it creates a solid foundation of benefitting the society as whole. However, utilitarian ethics ignore the struggles of people living in a micro level. One must acknowledge that minorities are essential part of society as they compromise. A prime example of this could be seen in this example. For instance, a train conductor is letting a bridge down for a train to cross. Suddenly, he sees his girls playing with the gears. Does he save his daughter or does he allow millions of people to be victims of death? These are crucial decisions that utilit arian ethics fail to answer. Similarly, Kant’s moral theory is not necessarily to focus in consequences necessarily, but rather focusing on an issue that should be done regardless of the burden it creates. The theory automatically assumes that an individual should naturally execute an action regardless of the consequences. An individual should commit to an action even it causes unhappiness and is not logical. This concept is extremely essential base on the fact that humans should not care if their actions are moral as long as they are ethical. For instance, one cannot blame someone else if they attempt to be nice but instead end up hurting the other individual. One must comprehend that that person had good intentions and meant well. Again, this is vital in the society that we live in because it creates diffusion and a moral viewpoint on conflicts and tensions that occur every day. Moreover, if the outcome that an

Collectivism vs. Individualism Essay Example for Free

Collectivism vs. Individualism Essay The research to examine the cultural norms of Korea as compared to that of US, is based on two particular core dimensions: United States as an individualistic country, and Korea as a collectivistic country. In fact, this is the first thing that comes to mind, knowing that collectivism vs individualism is a major characteristic that differentiates these two countries. Lifestyle and living arrangements In a study by Lee and Ro Um (1992), it is discussed about the major difference between Koreans and Americans in their evaluations of product attributes was the different weights each put on the importance of the family. Koreans tended to be more family oriented in their product evaluations than the Americans. This meant that the products were selected. Korea has a family-oriented culture. For a young couple, living with elders (parents) has been a cultural norm in Korea, although in United States this living style is unusual normatively and behaviorally. According to Korean National Statistics office, 1993, almost three out of four Koreans people aged 60 and over live with their children, a percentage of 74.7%. The percentage that lives with a spouse only is 13.2% and living alone, 10.6%. Explore the gaming culture of Korea Why South Korean people play games In South Korea more than half of the 50 million populations play online games frequently. Gaming in this country is not just a hobby but a way of life. Currently in the country are 10 professional gaming leagues which are sponsored from the successful corporations such as SK Telecom and Samsung.   According to a news article published CNN , in South Korea almost half of all games have been sold since the game launched in 1998. StarCraft is a legitimate business, ranking in hundreds of thousands of dollars in earning. According to a news article published in BBC [4], in South Korea games are nationally televised and they fill-up stadiums. Extremely popular is the multi-player gaming. Being a professional video-gamer is a serious business. They attract huge sums in sponsorship and can make more than $100,000 a year. Professional players in South Korea are treated like  sports stars. Some of the most famous players from league matches and sponsorship could earn more than $400,000 per year. South Korea hosts the annual World Cyber Games. The country registered more than 15 million people for online gaming, which is 30% of the population. Gaming Addiction and the Government Intervention in South Korea As a consequence as a strong video game culture, South Korea since early 2000s reports of addicted gamers dying or murdering loved ones in order to satisfy their addiction. When a mother tried to stop her son from playing games, he killed her. Approximately 14% of Koreans between ages 9 and 12 suffer from Internet addiction because there are cable channels devoted solely to the games.[5] South Korea has been treating the disorder for years. In 2002 the government opened an Internet-addiction treatment center. In 2005, a 28 years old South Korean man went into cardiac arrest and died after reportedly playing an online game called StarCraft for 50 hours straight. The man did not sleep properly and did not eat well. He just made few bathroom breaks and for very short periods of sleep. In 2006 the government opened a hotline for gaming addicts. Moreover, hundreds of private hospitals and clinics in the country opened specializes units to treat the disorder. In 2010 the government ordered a â€Å"nighttime shutdown† for gamers. This happened after police discovered a 3-month old baby who starved to death while her parents were busy with their virtual baby on a game. The Ministry of Culture, Sports and Tourism ordered the three most popular operators of the games to block people under age 18 from playing games between midnight and 8 a.m. The government has significantly slowed down the Internet connections of young players if they play for lots of hours into the night. More over in the National Assembly several other bills were pending that would control kids gaming habits. Where South Korean people play games South Korean entertainment industry is note based on home entertainment system such us console video game system, home theater etc. Instead it is created outside of the home in various places called â€Å"Bangs†. Recently South Korean people play games in the country’s Internet cafes, known as â€Å"PC- Bangs†. The PC Bangs are especially dominant in big cities like Seol, where  is a density of population. It is important that the PC-Bang industry now can provide computers and Internet service to those that previously did not have the economic conditions to possess these technologies. Analysts consider that the social environment of the PC-Bang is the most important factor to make the PC Bang attractive and popular to users. Other factors are: the high-performance computers, high-speed internet connection and low fee usage. [6] Most bangs are cheap; the patrons pay an hourly fee, ranging from $1.00 to $1.50 USD an hour. In South Korea going to a bang is the sam e as going to the bar in USA. Economic Conditions According to an article in About.com , the industry of video game has a large share of South Korea’s GDP. â€Å"According to the Ministry of Culture, in 2008 the online-gaming industry earned $1.1 billion dollars in exports. Nexon and NCSOFT, South Korea’s two largest game development companies reported a combined net income of over $370 million in 2012. The entire game market is estimated at approximately $5 billion dollars annually, or about $100 per resident, which is more than three times what Americans spend. Games like StarCraft have sold over 4.5 million copies in South Korea, out of a worldwide total of 11 million.† The same article says that video games stimulate the black economy of the country. What they play Relatively a small number of games are played in South Korea, the most popular of them are: League of Legends, FIFA Online 3, Sudden Attack, Lineage, Dungeon Fighter, Blade Soul, Aion: The Tower of Eternity, Echo Soul, Cyphers, World of Warcraft, StarCraft, Warcraft 3. [9] StarCraft- The most popular game in South Korea of all the times is StarCraft. Star Craft is a military strategy game, which is developed by Blizzard Entertainment. [10] World of Warcraft (WOW) Another popular game at most of the time is the World of Warcraft, developed by Blizzard Entertainment. World of Warcraft is a massively multi-player online role-playing game or MMORPG.

E-tailoring Online: Customer Views and Impacts on Services

E-tailoring Online: Customer Views and Impacts on Services Abstract An increasing number of customers are turning to the Internet to make their purchases, as a vast array of goods and services are now only a mouse click away. E-tailing clothes is even more challenging, with new e-tailers hoping to attract and retain satisfied online customers, are constantly creating new opportunities for them, and in order to do that they need to know what evaluative criteria customers use when selecting an e-tailer as well as what they will purchase online. Past research has provided some insight into what characteristics customers assess whilst making this choice. This report has not been without its limitations. Consequently, the present study utilizes a literature review, qualitative and quantitative research to identify the core customer behavior towards this channel, In addition, results of the analysis show that the type of product on offer and the web attributes (determinants) are predictors of customers attitude toward online shopping for clothing and their perception hence, providing an understanding of how they are responding to the new online buying opportunities. 1. Introduction This research report is divided into 5 Chapters. Chapter 1 is meant to introduce the background of the research area with aims and objectives and focus of the study providing guidelines into subsequent chapters. This then will be followed with Chapter 2 having literature review of the matter giving an insight of the research area that will be referred, compared with the data collection and analysis will be made in Chapter 4. However, Chapter 3 will be discussed prior to the actual data collection as it is necessary to identify Research Methodology to be used for the research. Finally, Chapter 5 will have conclusions and recommendations with any limitations faced and with the mention of area for further research if any. The expansion in electronic commerce (E-commerce) has been phenomenal, with most of todays business transactions being conducted through the Internet. The emergence of this electronic retail (E-tail) market has been extraordinary. E-tailing is also a gaining popularity and changing the retail landscape, it is pervasive in what we thought of it six months ago is probably different to what we think of it today and also what we will think of it in six months time. Customers decision making process has also altered greatly with the introduction of this medium and more so as an alternative channel for shopping. Online shopping concept has already caused a stir in the retail industry in the UK, as more people are opting to buy online due to various reasons, a vast array of goods and services are increasingly being made available now through a click of the mouse, creating a new experience and culture. Many retailers are already delivering high value, personalised products and services at a fraction of the cost thereby making it more low cost and also appealing to the consumers (Birch et al, 2000). The number of consumers shopping online has increased markedly, according to Jardine (1999) people have increasingly become price sensitive and often compare prices of goods both online and offline before making the final purchase, in turn increasing competition amongst the retailers. This is the general overview of the e-tailing concept, as understood b y most of us. However, the purpose of this study is to concentrate on the online clothing market in the UK specifically London, in order to determine predictors of customers purchase intentions for clothing products via this channel. E-tailing of clothing items online has always been debatable, especially since clothing are â€Å"feel-and-touch† products, and cannot be bought without engaging this sensory aspect, unlike other cognitive products like books, computer software, dvds and music which do not really require this. Nevertheless, customers tend to buy more clothing products when they perceive the features of the online store, such as a convenience and secure system of ordering and payment, returns policy, the focus on product display, and the offering of products that have a range of acceptable fits as opposed to a precise fit and most of all choice this are some of the most general attributes a customer considers whilst shopping online for clothes. The attributes that enhance the online experience can be particularly influential for products such as clothing, which generally require physical interaction and evaluation prior to purchase. Web experience attributes can affect early decision making stages (search and pre-purchase evaluation) and influence purchase intent of the customer. With the current fragmented nature of the subject area and to keep up with the rapidly developing technology as well the customer attitudes, the author aims to build on the current body of knowledge, investigating and drawing together the key aspects which influence online shopping for clothes, so as to understand how the customers are responding to the new buying opportunities presented to them by the e-tailers in UK then concentrating on London where the survey was conducted by collecting data from a sample of participants, which aided in exploring the capabilities and further to determine consumer behaviour and customer relationship management p atterns in relation to E-tailing, thus the research objectives being set as: 1. To explore the impact of e-tailing in London. 2. To determine customers attitude towards shopping online. 3. To investigate customers perception of shopping online for clothing in London. In order to achieve the results of the set objectives, the author has explored the determinants the customers consider most important when making a purchase online and to what extent they create an impact on their perceptions. The first hand elements collated from the survey has helped to gain rich insights into customers behaviour and attitudes towards this channel. The secondary data which is covered in the second chapter under the literature review the author here has studied and explained the general E-tailing concept and picked relevant data to help understand the subject matter and provide a better insight into the field of e-commerce, covering a wider area (UK), then narrowing it down to specific location (London) which in turn has helped to achieve the set objectives and later also support the resultant findings in terms of the primary data collected via the survey by the author. 2. Literature Review Xing (2001) stresses that â€Å"The emergence and explosive growth of e-commerce through online trading have ushered in a new era of retail business†. 2.1 The Commercialisation of the Internet The Internet, once a tax-sustained and a government-regulated endeavour, is no longer restricted to non-commercial traffic. The early commercialisation of the Internet, in the mid 1990s gave rise to the e-commerce phenomenon. The Internet population has since grown tremendously, as a result of its opening to the commercial traffic in 1991. Its utilisation has since become remarkably more wide and varied in businesses; the application of internet has grown rapidly over the last several years, due to its contribution of the ever evolving new information technology and its positive gains to the business organisations. Its use apart from being internal its also employed externally and its used more commonly referred to as E-business (electronic business) derived from such terms as e-mail and e-commerce, which is the conduct of business on the Internet, not only buying and selling but also servicing customers and collaborating with business partners. IBM was one of the first organisations to use the term E-business (electronic business) when, in October 1997, it launched a thematic campaign built around the term. Today, major corporations have reconsidered their businesses in terms of the Internet and its new culture and capabilities. Companies are utilising the Web to buy parts and supplies from other companies, to collaborate on sales promotions, and to do joint research, exploiting the convenience, availability, and world-wide reach of the Internet, using it successfully. 2.2 The E-tailing Concept â€Å"The emergence and explosive growth of e-commerce through online trading have ushered in a new era of retail business† says Xing (2001). It was seen as a new channel for sale of products and services along with the traditional channels as well as a market penetration strategy for others. E-tail or E-retail the term, came into discussions or rather its origins as early as 1995, its an addition in the computing subject such as, e-mail, e-business and e-commerce. The business of e-retail has been defined as the sale of goods and services via internet or other electronic channels, for personal or household use by consumers (Harris and Dennis, 2002). Its more efficiently used as a marketing tool, which is integrated into traditional business strategies, and also being viewed as a new marketplace by existing businesses as well as new business ventures as the market place becomes more competitive and unpredictable, due to this, the growth of the electronic retail market has been rapid, significantly expanding reach in terms of people, location and range being variety of information, the World Wide Web has created benefits for both the marketers as well the consumers. For consumers, the Web can provide access to a wide range of products and services with low cost (Bakos, 1997), extensive and tailored information, at home convenience for product comparisons, enhanced interactivity (Cross and Smith, 1995), hence facilitating the formation of virtual communities for users with common interests. E-tailing and E-trading operates in all four of the major market segments; business to business, business to consumer, consumer to consumer and consumer to business. Initially, much direct selling (or e-tailing) was taking place on the internet of computer-related equipment and software, one of the first to report successful sales in the millions of dollars directly from the Web was Dell Computer, there after other businesses started employing the concept in various fields from; Travel bookings, Holidays, Books, Clothing and other accessories, this has particularly grown in the Business to Consumer market segment directly or indirectly as a result of the wide usage of the internet. The Internets greatest commercial advantage is said to be the reduction in transaction cost that directly lowers the prices for consumer (Pavitt, 1997), and therefore E-tailing is said to be a low-cost, efficient way to display merchandise, attract customers, and handle purchase orders (Bellman, 2001). 2.3 Online shopping in the UK Home shopping in various forms has been available to the consumer market for more than 100 years in the UK, paper catalogue being the first and the oldest form illustrated with Victorian ladies and do-it-yourself house kits a lot has changed since, in terms of improvements and choice, then came the emergence of home shopping television, however none has had the influence or the expected impact of shopping, as much as the World Wide Web. E-commerce has grown steadily in the UK since the early 1990s. According to Exley (2006, cited in Haymarket, 2006) consumers have become comfortable shopping on the internet and e-tailing is clearly a part of retails future. He adds that e-tail does not have to replace traditional bricks and mortar stores, â€Å"all retailers need to do is to provide a good in-store experience† (Exley, 2006, cited in Haymarket, 2006). â€Å"Since 2000, Internet shopping has soared by over 5,000% with UK consumers spending an astounding  £200 billion during this period. Internet shopping is clearly the bright spot in the UK retail sector, but this industry is still young and has potential for further growth.† (Tina Spooner, director of information, Interactive Media in Retail Group (IMRG), cited in press release, May 2009). No doubt, online shopping is rising steadily in the UK (from a consumers perspective) as internet access has become cheaper, high street cyber cafà ©s are increasing and Internet service providers (ISPs) have already eliminated subscription fees (Daniel, 2000). Furthermore as technology is set to get even more advanced, hand-held devices have become internet-enabled and nowadays most mobile phones connect to the web (Daniel, 2000). With all the above possible ways of shopping more customers are getting accustomed to the online shopping experience and utilising the new channel. This exc eptional growth of Internet shopping is also driven by greater emphasis on customers efficient use of time, as well as the ever increasing number of computer trained customers, hence giving it a positive outlook and a further opportunity for growth to the existing and perspective e-tailers. A wide range of products and services are available for the customers in the UK to buy online from a variety of retailers, which also gives them a better choice, so why would they go buy anywhere else? Although one reason may be convenience, sadly another is fraud; fraud poses the biggest threat to online shopping (Economist, 2004) but according to Pavitt (1997) consumers fear of shopping online is already resolved by the use of encryption technology. Moreover, the security systems are rapidly improving by the day, further dispelling the notion which is perceived by a majority of people worldwide that online shopping is a risky business. For example, secure digital systems such as encryption tools, digital signatures and the guarantee about security or privacy concern provided by the e-tailers have reduced security inhibitors and thus have increased consumers willingness to visit or purchase from sites (Ah-Wong et al., 2001; Han and Maclaurin, 2002). UK is the second largest e-taling market in Europe like Germany, it combines a large consumer market with internet penetration above the European average (Datamonitor, 2002). There are six leading online shopping companies that dominate the UK e-tailing market. These are; streetsonline.co.uk, Jungle.com, Amazon.com, Lastminute.com, Thomascook.com and Egg.com, all these providing a variety of products and services. What is the future of high street stores when most analysts agree that in five years time, online shopping could be worth  £200billion? This does represent some form of concern to high street stores in the UK as a percentage or it could be of the sales they lose. Nevertheless according to Brewer (2006); cited in Haymarket (2007) the future is brightest for those high street stores that could adopt a multi-channel strategy. However, Murphy (2006); cited in Haymarket (2007) says that â€Å"we have the most vibrant, competitive high street in the world and high street shopping is one of our biggest leisure pursuits. Can high street shopping be our biggest leisure pursuits since they boast to sell a variety of diverse products in-store? It is the refore inconceivable that the future of retail would be solely online†, although the number of customers making purchases online is also on the rise in the UK as mentioned earlier in this report. 2.4 The extent to which e-tailing builds relationships The impact of e-tailing will be felt differently and at different times by various retailers. In the context of buyer behaviour preferences (Daniel, 2000) says that e-tail is a transactional-sales medium rather than a relationship-building medium which means that e-tail cannot substitute personal contact such as customer service advisors, that makes it the most critical differentiation aspect to high street stores today. This emphasises the need further research on the customers perception of e-tail, i.e. to what extent does e-tailing build relationships? If empirical research suggests that e-tailing is a transactional sales medium then ultimately there may be an opportunity for e-tail to focus building relationships with customers that will create the need for further research on how e-tail may be able to become a relationship-building medium. Personal contact with highly trained and motivated salespeople, the service factor is still the critical differentiator for such businesses, and on-line experiences have yet to match that or offer a suitable counter value (Quelch, 1999 cited in Maruca, 1999). As Pavitt (1997) states that the impact of e-tail on high street stores may result in changes on three key fronts; â€Å"change in the nature of product offerings, customer buying patterns and its place in the value chain†. The changes in product offering may alter as a result of advances in digital technology. For example media products delivered via the internet or newspapers being published electronically, that would be a direct impact on high street stores (Pavitt, 1997). There is lack of empirical evidence to show what customers perceive of digital medium against physical goods, as an simple example, would customers prefer buying a DVD from a high street store, so as to get a feel of the physical aspect of this product as well as more information from the back cover of the DVD case, or from the Internet where information on the product is limited in two dimensional form. â€Å"There will be a great deal of change in the value chain as well due to shrinkage in distribution channels†, (Bellman, 2001). E-tailing eliminates traditional chain of wholesalers, agents, and other intermediaries thus creating a new distribution model focusing on manufacturer to consumer direct that implies a great potential for savings (Bellman, 2001). Today, majority of the manufacturers do not want to take the responsibility of dealing with single customer queries, which is one reason why they sell their products through intermediaries even on the Internet. With lack of evidence it still remains to be investigated as to what extent is the internet an intermediary? Another common question which arises in this case is; do e-businesses have any storage for products they advertise or do they order them directly from the manufactures or other traders as required? However, this can also be different in the case of businesses which use internet as a secondary channel for sell or distribution of their products, which they also sell in their physical store. Another issue that arises is to investigate potential shoppers perception in relation to price. Smith et als (1999); cited in Lii and Lee (2005) indicated that online shoppers believe that online stores enjoy a cost advantage over traditional channels in terms of administrative cost, overheads and transaction cost. These features of the online retail channel add to the perception of online shoppers that prices generally tend to be much lower online than that of the high street stores. Considering this then, do customers shop online because they perceive it to be cheaper? If so then how and in what w ays is online shopping cheaper compared to the high street stores where lots of products are reduced at competitive prices even at times with offers such as buy one get on free or a second product at half price, are always there. Is price an issue of concern or is it about building relationships? Would customers be willing to pay that extra price in exchange for good service, remains to be investigated? Good service may be classed by online shoppers such as providing a tracking system for their ordered goods, free return policy and delivery of the goods or a full money back guarantee on items that customers return which is in place with most e-businesses today. With regards to customers online shopping behaviour, Brown (2000) states that a survey by BT found out that consumers choose well-known brands when shopping online and those consumers want to be served immediately, be remembered and treated as individuals. Therefore, in what ways can e-businesses build relationships? According to Kalyanarm and Winer, (1995); Chandrashekaran, (2001); cited in Lii and Lee (2005) prior studies have revealed that in the off line retail channels, customers may use the advertised original price as a frame for reference to assess the accompanying sale price. The resulting price comparison between the original price and the sale price makes the price promotion more appealing (Biswas and Blair, 1991; Grewal et al, 1996; cited in Lii and Lee, 2005). On the other hand on line retailing enables potential customers to have quick and easy access to price and other product attributes and information necessary for price evaluations. An example is amazon.co.uk websit e. The Internet has empowered on line shoppers to better detect price discrepancies and bargains (Balasubramanian, 1997; Bakos, 1997; Hoffman and Novak, 1997; cited in Lii and Lee, 2005). Today Majority of e-tailers attract customers through promotion codes normally available through advertisement and marketing media from which customers, can usually claim some money off or some percentage of discount on their online shopping. What remains to be assessed is whether the promotional codes attract new customers and also retain existing customers to shop online? If e-tailers start providing regular promotion codes to new customers as well as regular customers with this, then will it add up to building a relationship? 2.5 Customers general online shopping preferences in the UK On the basis of the objectives of this research, its crucial to investigate customers e-tail shopping preferences in the UK in general first, since ultimately perception leads to action. â€Å"When consumers are confronted by new forms of retail channels such as on line shopping, they may decide whether the difference between the on line shopping and off line shopping is significant to them. If the difference is perceived to be insignificant, customers may classify the two retail channels as the same. On the other hand, if the differences are perceived as significant, customers may classify the two shopping channels as different and make their purchase decision differently† (Lii and Lee, 2005). â€Å"Perception involves the process of categorization, and people tend to place new experiences into existing classifications of familiar experiences† (Monroe, 1990; cited in Lii and Lee, 2005). Late night shopping in the UK is fast becoming a way of life and a new culture, since for many people 24-hour high street shopping is invaluable as it allows them to fit it around their lifestyles, this is very common in the larger cities like London where this sort of service fits in well with the metropolitan lifestyle whereby time is crucial, however having said that, its also being almost equally favoured by people living in smaller towns or suburbs. The changes occurring in buyer behaviour patterns are alarming to high street retail stores as more and more people are beginning to work partly or wholly from home and they may prefer their goods bought online to be delivered at home, this is also rapidly picking up for supermarkets where the consumers prefer their grocery as well as other items shopped on line to be delivered at their doorstep (Haymarket, 2006). Whatever may be the case, Cottam (2006, cited in Haymarket, 2006) says that high street retailing is facing stiff competition with on line ‘anytime culture, meaning that customers are shopping 24/7 and therefore even high streets supermarkets such as Asda and Tesco have also launched 24-hour stores. Customers perceptions about 24/7 shopping remain to be investigated, since some high street supermarkets that tend to provide 24/7 services are closed on Sunday afternoons due to Sunday trading laws, but this has also changed in recent years. Once more it raises the question, what are customers perception of 24/7 culture in relation to the internet and high street stores, a fair example to portray, the 24/7 concept proved to be costly, in comparison to profitability against cost, for a superstore like Sainsburys as Sainsbury failed in its attempt, even though it believed it had the winning formula (Haymarket, 2006). The reason behind the failure was that Sainsburys could not attract enough customers as there is no guarantee that a fair percentage of existing or new customers will change their habits to take advantage of 24-hour shopping (Haymarket, 2006). Indeed this is a lesson for others (organisational learning) and thus most retailers are being cautious in their approach to 24/7 services. Bearing this in mind customers are constantly taking advantage of such facility and are trying or even getting used to shopping around the clock says Gladding (2006, cited in Haymarket, 2006). Analysts argue that 24-hour retailing is less likely to grow beyond its current levels as retailers have raised little awareness of the fact, hence stores such as Asda and IKEA are being cautious about this approach by advertising their long opening hours in the form of outside signage and flyers (Haymarket, 2006). The key question that arises from this scenario is the customers perception of the availability of 24/7 online shopping versus the high street 24/7 timings. Do customers really want go to shopping at high street stores and supermarkets at night (freely) compared to doing online shopping at night? Security is another issue that could be a vital sign of failure for high street stores or supermarkets to remain open 24/7 and be able to achieve their budget. Depending on the type of product, Andrew and Currim,(2004) have highlighted some key characteristics of customers shopping on line, despite the additional aspects. They say that consumers shopping online for products such as groceries differ from those who shop in high street stores claiming that on line grocery shoppers tend to be more frequent, heavy shoppers, less price sensitive, prefer larger sizes and do more screening on the basis of brand names. Alternatively, Morganosky and Cude ,(2000) suggest that convenience is the main motivation for on line shoppers, and according to Keh and Shieh,(2001) on line shopping is ideal for time-starved customers such as couples with two careers, children, and above-average income who want to spend time with their families instead. These suggestions are valid and can be applied to the reasons for consumers behaviour towards shopping online, however it also differs to the type of market and the products on offer. Hence, for those people, conven ience is more of a priority than price stresses, Keh and Shieh, (2001). Also Professionals, working women and single independent hard working individuals are just some of the people who do not have time on their hands and their perceptions of online shopping especially for items such as grocery remains to be determined. Keh Shieh, (2001) simply claim, with being deficient in practical evidence, that such customers dislike grocery shopping and only those with busy schedules will consider on line purchasing as a viable option. Online shopping may save time and money as the frustration of dealing with children at a store or supermarket that involves pushing carts up and down the aisles, waiting in long lines at checkout counters, and finding parking spaces, could be eliminated, Keh Shieh,(2001).Whilst on the other hand, as more people today having the opportunity to â€Å"surf† from their offices, they are more likely to shop during office hours and thus may prefer to collect their online shopping at ‘convenient stores on their way back home (Pavitt, 1997). Vaughan (1999); cited in Jardine (1999) head of consulting at Retail Intelligence says that â€Å"consumers might do their main shopping on the internet once a week but will still need to stock up on fresh foods locally† and this is the alternative method that supermarkets have taken by opening ‘convenience stores such as Tesco Express, Sainsburys Local, and MS Simply Food, (Jardine, 1999). According to Lii and Lee (2005), their study on examining customers perception of shopping on line suggests competitive pricing being the main reason. It allows them to compare prices of products more quickly and easily than when shopping in stores. (Korgaonkar and Wolin, 1999; Ernst Young, 2001; cited in Lii and Lee, 2005). According to the author, Mysupermarket.co.uk is a classic example; The website allows registered shoppers to compare their online shopping from high street supermarkets in the UK which are Tesco, Asda, Sainsbury and Ocado which is fully online based. Furthermore it allows users to switch at a click if they decide to change their preference to the cheapest supermarket. The problem associated with this is that it may be time consuming going through the tedious process of comparison because consumers may dislike switching from their preferred supermarket. In the authors view high street supermarkets also offer this service. A good example is that of Sainsburys supe rmarket where there is often a price comparison sheet placed next to their own shelf edge price tags showing their prices as compared to Tesco and Asda. If not then Sainsburys have opened small kiosks often located towards end of an isle where the customer advisor can compare their prices for customers with other competing supermarkets and if their prices are high then they do price match or sell the item even cheaper. This shows that the high street physical stores are also doing their best to match the benefits of on line shopping. Another factor that may drive away consumers from shopping on line is transportation cost. Bellman (2001), says that growing numbers of e-tailers are eliminating these costs as they find that customers often cancel orders after going through the entire ordering process and then considering the transportation cost being high, and this may be the key factor that drives potential customers away. The other fear of shopping online is privacy. Most web users refrain giving out their details, especially data in the form of credit card details as they fear exploitation of their privacy (Bellman, 2001). Insufficient product information on screen also contributes to decline of purchase. Apart from this, all secured websites do have a ‘time-out function where user sessions are based on time limits. If ‘time-out occurs, customers risk losing their entire shopping basket, which is quite frustrating from a customers point of view. These are some of the most common factors which may keep away customers from shopping online and reason their preference to shop in high street stores simply because they are well aware of the location, store layout, product selection and return policies as well as the stores reputation (Greenbury, 1999; cites in Maruca, 1999). Online e-tailing has a great and growing future, but the high street is still an important destination for customers. The limiting factor of e-businesses could be, a simple example, such as one cannot buy a piece of fruit via shopping online but can do so from a store. Furthermore, there is no empirical evidence to justify what drives customers to shop on line instead of high street stores, ultimately questioning what customers online shopping preferences are? 2.6 The E-tail clothing sector in UK Fashion is a sensitive and rapidly moving market which is growing at a faster pace in the UK, in comparison to its other European counter parts. Shopping on line for clothing products is also fast gaining popularity in the UK. Although buying over the Internet remains small in comparison with buying through the traditional channels, such as the brick-and-mortar physical stores, it is growing and clothing is a substantial portion of the e-tail sector in the UK. The online clothing sector caters for almost all segments of the UK market starting from the low cost value clothing to high end designer clothing including bespoke tailoring to couture clothing, the choice is unlimited and the options ever increasing. One can buy a single handkerchief to a full suit online, even clothing and accessories for all age ranges are available, whereby the customer can buy clothes for new born babies to clothes for senior citizens, therefore making this shopping Diabetes: Questions and Answers Diabetes: Questions and Answers DIABETES Diabetes Mellitus The medical name for diabetes mellitus comes from the Greek word that means to siphon and the Latin word that means sweet like honey. Diabetes mellitus is the name given to a group of conditions where there is too much glucose in the blood. It affects approximately 3% of the population. There are currently 1.4 million people with diabetes mellitus in the UK and it is expected that by 2010 that there will be a further 1 million. It costs the NHS 4.9 billion a year and affects a million people without them even knowing that they have it. (Devendra et al 2004) RELATED BIOLOGY Which organ is involved in the regulation of Blood Glucose Levels? The pancreas. Where is it located? Retroperitoneally, within the curve of the duodenum and with the tail extending to the posterior surface of the spleen. What type of tissue is it made up of? Primarily glandular tissue that has both endocrine (Insulin) and exocrine (Pancreatic digestive enzymes) functions. Which area of this organ is responsible for producing the hormones involved in the regulation of blood sugar levels? The Islets of Langerhans What are the main functions of insulin? To reduce the levels of blood sugar by facilitating the uptake of glucose from the bloodstream into the cells. It increases the rate of glycogen synthesis in the liver It promotes the synthesis of fatty acids in the liver It inhibits the breakdown of fatty acids in adipose tissue It stimulates the uptake of amino acids It increases cell permeability to potassium (after Wills C et al 2003), What type of substance is insulin made of? Circle the correct answer. Carbohydrate Protein Fats Name the calls that produce the hormone glucagon. Alpha cells What are the main functions of glucagon? An insulin antagonist, it raises blood glucose levels by increasing hepatic glycogen breakdown. It activates hepatic glyconeogenesis It enhances lipolysis of triglycerides One of these hormones has a Catabolic action and the other an Anabolic action. State what these terms mean and identify which hormone falls into which category. CATABOLIC Catabolism is the breakdown of complex biological molecules into smaller component ones Glucagon ANABOLIC Anabolism is the synthesis of complex biological molecules from simpler components. Insulin What are considered normal limits of blood sugar readings? Fasting blood sugar 3.0 to 6.1 mmol/l (Client note: this is variable I have quoted WHO figures – check what your tutor recommends and add it here!) Those with levels of 6.1 to 7.0 mmom/l are said to have impaired glucose tolerance (WHO 1985) CLASSIFICATION OF DIABETES MELLITUS State the 4 main categories. To the client: this is a loaded question. There are many different classification schemes. I quote the categories as defined in RECD 1997 Type 1 diabetes mellitus Type 2 diabetes mellitus Gestational diabetes mellitus Secondary diabetes mellitus – includes: Genetic defects of beta-cell function Genetic defects in insulin action Diseases of the exocrine pancreas Pancreatitis Trauma/pancreatectomy Neoplasia Cystic fibrosis Hemochromatosis Endocrinopathies Acromegaly Cushings syndrome Glucagonoma Pheochromocytoma Hyperthyroidism Somatostatinoma Aldosteronoma Drug- or chemical-induced Vacor†  Pentamidine Nicotinic acid Glucocorticoids Thyroid hormone Diazoxide Beta-adrenergic agonists Thiazides Phenytoin Alfa-interferon Infections Congenital rubella Cytomegalovirus Uncommon forms of immune- mediated diabetes Other genetic syndromes sometimes associated with diabetes Down syndrome Klinefelters syndrome Turners syndrome Wolfram syndrome Friedreichs ataxia Huntingtons chorea Lawrence-Moon Beidel syndrome Myotonic dystrophy Porphyria Prader-Willi syndrome (RECD 1997) Diabetes mellitus can be due to a deficiency in insulin synthesis, secretion and also in some cases resistance. It is also thought that some diabetics may have a combination of both. State 5 causes of Primary Diabetes Mellitus [aetiology]. Primary Diabetes Mellitus is subdivided into Type 1 and Type 2 varieties Aetiology of Type 1 is multifactorial. It is auto immune and trigger factors can be genetic or environmental Environmental causes include exposure to Coxsackie B virus, Rubella virus and Cytomegalovirus and exposure to cows milk. Aetiology of Type 2 is also multifactorial. It includes genetic factors and environmental factors including: western diet, lack of exercise, obesity and hypertension (Todd W et al 2000) NB Causes are still unknown, the above are thought to be trigger factors. State 4 causes of Secondary Diabetes Mellitus. Causes of secondary Diabetes Mellitus. There are several types of secondary Diabetes Mellitus including: gestational diabetes malnutrition-related diabetes pancreatic diseases causing diabetes endocrine diseases causing diabetes drugs and chemicals causing diabetes genetic conditions causing diabetes Causes depend on the variety but include pregnancy, pancreatitis and various drugs including: steroids thiazide diuretics phenytoin diazoxide streptozotocin Pancreatic diseases can cause Diabetes Mellitus including: acute and chronic pancreatitis pancreatic carcinoma cystic fibrosis haemochromatosis Disease processes can also cause secondary Diabetes Mellitus including: acromegaly Cushings syndrome glucagonoma phaeochromocytoma Complete the following chart by using the recommended textbooks to compare the two main types of Diabetes. TYPE 1 TYPE 2 Age at onset juvenile ( % of all cases about 10% about 90% Acute/insidious acute insidious Body build lean obese Genetic link high low Prone to ketoacidosis yes no Autoimmune Disease yes no Treatment insulin diet, oral hypog’s (Harris M 1995). What age group in the general population has the highest incidence of Type 2? Typically the 55-75 age range (Harris M 1995). Certain groups in the general population have an increased risk of developing Type 2 and currently Diabetes UK is promoting a campaign to identify those most at risk earlier, so that they do not develop the major complications associated with this chronic disease. This is called the Missing Million Campaign. Names these â€Å"At Risk† Groups 1. History of Heart Disease 2. History of Stroke 3. Obese (BMI>30) 4. Over 50s 5. Over 40s if from African Caribbean or Asian backgrounds PATHOPHYSIOLOGY / CLINICAL FEATURES DEFINITIONS Define the terms:– Gluconeogensis Biosynthesis of glucose from sources other than glycogen Glycogenolysis Oxidisation of hepatic glycogen into glucose Briefly describe how insulin deficiency / absence can cause the above processes to occur. Insulin deficiency and/or low glucose levels promote the secretion of glycogen Glucagon promotes the activation of the enzyme adenylate cyclase in the liver which triggers glycogenolysis. This is exactly the opposite process to gluconeogenesis and is mediated by a number of enzymes, the most significant being pyruvate kinease Clinical Presentation – Complete the following When blood glucose levels arise above a certain amount the renal threshold in the kidneys is exceeded and glucose spills over in to the urine. This is called glycosuria. This excess glucose sucks up the water so that it can flow from the body; this is called. Large amounts of urine are excreted. This is called polyuria. Excessive thirst is called polydipsia. Excessive urination can result in lowered blood pressure and shock. Blurred vision can be caused by fluctuations in the amount floaters and water in the lens of the eyes during periods of dehydration. This is called osmotic myopia of the lens. Cells are not able to access glucose so they do not receive any fuel and as a consequence cannot produce energy. This triggers the brain to send a message of hunger. This excessive hunger is called polyphagia. Lack of energy makes the individual feel tired and weak. Other sources of energy are sought. Fat stores are broken down to provide energy. This may result in ketosis. Breakdown of fats results in the production of ketone bodies which are excreted in the urine. These are acidic and alter the blood PH. There is a sweet smell of ketones on the breath. This is called ketotic respirations. Weight loss also results. Breakdown of protein stores results in muscle wastage. Skin infections are common e.g. Staph boils, erysipelas . Excess glucose suppresses the natural defence mechanisms and the action of the lymphocyte* cells. Electrolyte imbalances occur. The electrolyte potassium affects cardiac muscle causing arrythmias if deficient. Urea and electrolyte imbalances also result in the following symptoms 1. Dry mouth 2. Thirst 3. Muscle weakness 4. Lethargy 5. Cardiac arrythmias. Numbness and tingling in the feet and cramps may result from peripheral neuropathy. Client Note (*)– this is debatable – your tutor may have a specific answer in mid for this one The recommendations of the W.H.O â€Å"Definition, Diagnosis and Classification of Diabetes Mellitus and its Complications† were formally adopted in the UK on the 1st June â€Å"2000. The key recommendation, with regard to diagnosis is that fasting plasma glucose should be lowered from 7.8mmol/L to 7mmol/L. What is an OGTT? The Oral Glucose Tolerance Test In the oral glucose tolerance test the patient, after fasting for 15 hours, drinks 75 g of glucose in 300 ml of water, over 5 minutes. Blood glucose is measured before the drink and after 30, 60, 90 and 120 minutes. Urine is collected before the drink, and after 60 and 120 minutes. Before the test, for a period of 6 hours, the patient should avoid smoking and drinking coffee. There is a normal glucose tolerance if the venous plasma value is less than 7 mmol/l after the 2 hour period, If after 2 hours after the glucose load the value is between 7 and 11 mmol/l, then there is impaired glucose tolerance. If glucose is greater than or equal to 11.1 mmol/l this is diagnostic of Diabetes Mellitus OTHER TESTS / SCREENING PROCEDURES What is an HbA1c Test and why is it carried out? This is a measure of glycosylated haemoglobin in the blood. It is a longer term measure of the degree of blood glucose control. (DCCRG 1993) NICE target is 6.5 7.5 HbA1c When would Urea and Electrolyte levels and Blood Gases be tested? Normally only if metabolic imbalance is suspected, dehydration, renal involvement or occasionally as a screen for end-organ pathology (kidneys). U’s + E’s may be requested as part of a monitoring procedure. Blood gases may be useful if severe ketoacidosis is present. When would a Full blood count, specimen check and chest X-rays be carried out? This is more likely to be done as a screening or monitoring procedure (FBC or Urinalysis) unless there was an obvious clinical reason for doing them such as suspected anaemia etc. A CXR would be less likely to be carried out unless pulmonary or cardiac pathology was suspected (Client: this is contentious – as different clinicians have different rationales for these investigations.) When would and ECG and Lipid levels be checked? ECGs are likely to be checked on diagnosis, as a monitoring procedure or if arrythmias have been detected. They may also be done as a baseline investigation, with hypertension or if cardiac involvement is suspected. Lipids are very likely to be abnormal in Diabetes Mellitus. They would be checked as a monitoring investigation at most visits. (DCCRG 1993) When would a neurological assessment and inspection of the lower limbs be carried out? Peripheral neuropathy and vascular impairment are common sequelae to Diabetes Mellitus and this would be actively considered and evaluated at each monitoring visit. Probably at least twice a year or more frequently if indicated. (DCCRG 1993) Why are protein levels checked? Proteinuria is a good indicator of diabetic nephropathy. Urine protein should be checked at every monitoring appointment. Serum proteins are less sensitive but if renal pathology is established then it may be a useful investigation. (DCCRG 1993) When is urine checked for ketones? In the presence of dehydration, clinical suspicion of ketonuria, pregnancy and as a monitoring procedure. (DCCRG 1993) When would an eye inspection / photography be carried out and why is this done? Retinopathy is a potent cause of visual impairment and commonly found in the diabetic state. It is commoner with poorly controlled Diabetes Mellitus and Type I diabetes mellitus. It is one of a number of ophthalmic complications seen with diabetes and should be actively screened for at every routine visit. (DCCRG 1993) Why would a diabetic require having their blood pressure regularly recorded and what value is recommended? Hypertension is a common cardiovascular complication of Diabetes Mellitus and is an independent risk factor in Type II diabetes mellitus. The presence of hypertension and Diabetes Mellitus coexisting in the same patient will increase the overall morbidity risk of both cardiovascular disease and cerebro-vascular accident. A blood pressure reading below 130/85 mmHg is an ideal goal for most people with diabetes who dont have kidney complications, but some authorities may recommend an even lower blood pressure goal (below 120/75 mmHg) for people with diabetes who have kidney complications. (DCCRG 1995) State the main complications Short-Term Hypoglycaemia, dizziness, lethargy, impaired conscious level – drowsiness. Hyperglycaemia, nausea, headache, malaise, ketosis. Coronary heart disease, Cardiovascular disease (macro- microvascular disease) Retinopathy which can lead to blindness Nephropathy, which can lead to kidney failure and the need for dialysis Neuropathy which can lead to, among other things, ulceration of the foot requiring amputation Microvascular Retinopathy, Nephropathy Neuropathy These are generally related to HbA1c levels with the highest incidence of complication occurring when HbA1c levels are above 12% Atherosclerosis Arteriosclerosis Both processes can lead to : heart disease stroke peripheral vascular disease (Stratton I et al 2000) What are the SIGN Guidelines and name those that relate to Diabetes. A set of guidelines originally drawn up by Scottish Intercollegiate Guidelines Network. They include: visual impairment (SIGN 4) pregnancy (SIGN 9) children and young people (SIGN 10) renal disease (SIGN 11) foot disease (SIGN 12) cardiovascular disease (SIGN 19). Treatment- Give Principles   Type 1 Always insulin dependent. Active treatment involves titrating insulin dose against glucose levels and then maintaining levels by manipulation of the insulin regime Constant monitoring by either patient or physician Constant vigilance for complications Type 2 Depends on cause, but in most cases treatment involves lifestyle modification, weight loss, dietary carbohydrate restriction. If not successful then progression to oral hypoglycaemics and occasionally to insulin. Constant monitoring for the presence of complications Reduction of secondary causes of complication i.e. cessation of smoking. INSULIN Insulin was identified as a substance that prevented diabetes in the early 1890’s. Banting and Best extracted insulin from the pancreas of a dog in 1921 and the first human received a crude extract of insulin from the pancreatic glands of cattle in 1922. Over the years there have been many advances in the synthesis of insulin. Insulin is a protein. Insulin injections are vital for people with Type 1 diabetes as they are unable to produce insulin them selves and also for many with Type 2 diabetes whose condition has progressed to a point where tablets and diet cannot control it adequately. The aim of this treatment is to ensure that blood glucose levels are maintained at less that 6.5 mmol/l. (Client: see previous comments) Name 4 factors which influence control 1. Weight 2. Severity of disease process 3. Diet 4. Level of exercise (Wing RR, et al 2001) There are a variety of insulins available on the market. The two main sources are animal and human. How is human insulin produced? By recombinant DNA technology inserting human genes into bacteria such as E.coli which then produces insulin in commercial quantities. The majority of diabetics are now on Human insulin but unfortunately some people are still required to take animal insulin. Many drug companies are wishing to phase out animal insulin and at present Diabetes UK is campaigning to maintain these. Why does insulin have to be given by injection? Being a protein it cannot be given by mouth as it would be denatured in the gastro-intestinal tract. What other route is being researched as an alternative? A great deal of research has been lavished on alternative modes of drug delivery. Transdermal routes do not give reproducible and consistent blood levels. Oral insulin has not been a possibility in the absence of a specific peptide carrier system that would work in the gut. Nasal administration has been tried, but there was low bioavailability and absorption enhancers were needed, in addition the clinical effect was only over a very short period. Pulmonary routes appear to be promising but we already know that the pulmonary route is comparatively inefficient and requires ten times the amount of insulin to achieve the same clinical effect. Initial clinical trials show no side effects and research is currently continuing. (Heinemann L 2001) SIDE EFFECTS Initially on the commencement of insulin people may experience sensitivity around the injection site. How would you recognise this? This is a form of allergy. It can be local, in which case the local skin becomes red and itchy at the injection site. It may (rarely) be systemic giving rise to a uticarial reaction, tachycardia and tachypnoea. Very rarely a patient may experience anaphylaxis. Symptoms of hypoglycaemia may occur if too much insulin is injected or if not enough carbohydrate is consumed or if there is increased exercise without taking extra food. Hard lumps under the skin may occur at injection sites if they are not rotated. What is the correct medical term for these? Lipodystrophy The number of units prescribed is calculated depending on time of day, age, weight and lifestyle. Typical dose is 0.7-1.0 units per Kg of body weight. WARNINGS Insulin should never be administered in cases of HYPO. The body may get used to low levels of blood glucose and therefore the warning signs for HYPOs are reduced. Individuals who have lost these may be advised to raise their blood glucose levels slightly for up to 3 months to resensitise themselves to symptoms. Some people have also found that they have lost some or all of their symptoms of HYPO when transferring from animal to human insulin. Insulin dosages may have to change if there is disease of the adrenal pituitary and thyroid glands and also in the presence of liver and kidney disease. Taking of steroids will increase the insulin requirement. During illness, puberty or emotional trauma glucose levels can become elevated and therefore insulin doses require to be adjusted and more regular blood sugar monitoring is essential. During pregnancy insulin requirements may decrease in the first trimester and increase in the second and third trimester. The following drugs may increase blood glucose levels and therefore lead to a need for more insulin – Steroids Contraceptives Asthma Inhalers Some drugs lower blood glucose levels and therefore result in a reduction in insulin. These are:- Aspirin Beta blockers Mono-amine oxidase inhibitors. There are four categories of insulin. Give an example of each. Very short acting [ANALOGUE] – e.g. Humalog. Short acting [SOLUBLE, NEUTRAL] – e.g. Actrapid, Human Velosulin. Medium and long acting [ISOHANE, PROTAMINE ZINC] e.g. Human Insulotard. Combination of short and medium acting [MIXED, BIPHASIC] e.g. Human Mixtard. Who would most likely be prescribed very short acting insulins? The very unstable or out of control diabetic. Children more likely than adults. How long before a meal does short acting insulin require to be injected? Depends on type. Sol. Insulin starts working within 30-60 mins and lasts about 6-8 hrs. Other types such as Insulin aspart and insulin lispro both start working within 15 minutes and last for up to five hours. The glucose rise after a meal typically begins within about 15 mins so the insulin should ideally be in the system to counteract it. How often daily would you require to take the following insulins:- Short acting – about 2-4 times a day( when stable) Medium acting – about twice a day Long acting – Once (or perhaps twice) a day These answers depend on the age and size of the patient, as well as the severity of the disease process. Why is short acting insulin sometimes given with medium acting insulin? To give a smoother blood glucose profile and also to â€Å"fill in the gap† before the medium acting insulin becomes biologically active. Where should insulin be stored? In the fridge, but not frozen. Briefly discuss the types of equipment that are used to administer insulin? Commonest is still the disposable insulin syringe. Syringe should always be calibrated to match the insulin type. Most are U-100 now. Other options include the pen devices (expensive but convenient and largely â€Å"fool proof†). Jet injectors are occasionally seen, but not very common. In hospital surroundings insulin pumps (drivers or infusers) can be used. Ambulatory subcutaneous pumps are increasingly used to deliver continuous infusion. Very expensive but arguably capable of producing the best control. (HSG 1997) What advice would you give to a diabetic who is planning to go abroad on holiday with regard to their insulin? Take plenty with you as your brand may not be available abroad. Make sure you can keep it refrigerated. Run your blood glucose levels slightly higher than you are used to a) because of probable increased exercise and b) to reduce the risk of Hypo whilst away from home. Be extra vigilant with the blood sugar monitoring. Strange diet may have unexpected consequences. ORAL HYPOGYCAEMICS Below are the main categories of drugs. Give an example of each, including daily dosage and side effects? Sulphonylureas Chlorpropamide 250 mg (100 mg in the elderly) This is a very long acting drug, usually taken once daily with breakfast. Alcohol may cause flushing to the face. Biguanides Metformin Start at 500 mg twice a day or 850 mg once daily. The maximum daily dose is 2550 mg given in three divided doses Gastrointestinal side effects are a common occurrence in people taking metformin. Problems often include bloating, flatulence, nausea, stomach cramps and diarrhoea Occasionally a metallic taste in the mouth. Rare complication lactic acidosis (Knowler WC et al 2002) Prandial glucose regulator Repaglinide 0.5 to 4 mg with each meal Occasional gastro intestinal side effects (Bokvist K et al 1999) Alpha glucosidase inhibitor Acarbose 50 mg then titrated against clinical effect. Flatulence soft stools or diarrhoea. Glitazones [new drug] Rosiglitazone 4mg as starting dose increasing to 8mg if required Possible toxic effects on the liver (theoretical rather than practical) (Park JY et al 2004) ACUTE COMPLICATIONS The most common is Hypoglycaemia. It results from an imbalance between glucose intake, endogenous glucose and glucose utilisation. A decrease in the blood glucose level normally leads to stimulation of catecholamine secretion. Identify 5 causes. Insufficient carbohydrate intake Excessive carbohydrate utilisation (exercise) Intercurrent acute illness Overdose of insulin Other illnesses (viz glycogen storage diseases) Alcohol Name 8 clinical features that the patient experiences. Pallor Shaking Perspiration Fatigue A feeling of weakness Rapid heartbeat (Tachycardia) Hunger Agitation Difficulty concentrating Irritability Blurred vision Temporary loss of consciousness Confusion Convulsions Coma. What would be given in order to treat it? Depending on severity. If minor, warm sweet (glucose containing) drinks If major, IM Glucagon. Monitoring essential until fully recovered. What is ketoacidosis? A clinical condition almost invariably associated with low insulin levels. As a result, the blood glucose levels rise and the intracellular glucose levels fall. This requires the metabolism at a cellular level to be fuelled with fat derivatives rather than carbohydrates and this produces acidic ketones. These ketones normally require the presence of insulin for their catabolism. In its absence, they build up causing a metabolic acidosis and spill over into the urine when the concentration is high enough. Identify 5 causes Fluctuations in insulin regime Intercurrent illness Trauma Reduction in carbohydrate intake Dehydration +- severe exercise State 10 clinical features of this clinical state High blood sugar levels Frequent urination (polyuria) and thirst Fatigue and lethargy Dry skin Facial flushing Nausea Vomiting Abdominal pain Fruity odour to breath Rapid, deep breathing (Air hunger) Muscle stiffness or aching Coma The principals of management are:- Prompt administration of insulin (usually on a sliding scale) to reduce the hyperglycaemia and ketonaemia Replacing fluid loss (from polyuria and vomiting) usually by intravenous fluids Restabilising electrolyte imbalances secondary to dehydration, metabolic acidosis and hypokalaemia. Treatment for any underlying cause such as infection. LONG TERM COMPLICATIONS There are 10 steps that the diabetic patient can take to reduce his chances of developing complications. Regular screening of BP and maintain at 140/80 or lower. Regular HbA1c testing. Maintain blood glucose levels between 4-7mmols/L before meals. A