Management of type 2 respiratory failure definition,diabetes medicine online shopping,type 2 diabetes hypo or hyper 412s - Plans Download

An obese 86 year old female is bought to ED by private car with a 5-6 day history of progressive dyspnoea and fevers. Whilst we commence fluid resuscitation, IV antibiotics & early goal-directed therapy, we decide to trial non-invasive ventilation as a temporizing measure. Her pathology [?pneumonia ??ARDS] is not easily reversible & will take time to resolve. Essentially, we make a conscious decision to commit to a delayed sequence intubation ….
For my mate Alex & I, it served as a brilliant display of the powerful influence that online learning, podcasts and FOAM can have on our everyday practice. I still think the decision to delay the RSI gave us time to prepare her (& ourselves) for the difficult task ahead, particularly the PEEP and 100% O2 optimising her pre-oxygenation.
Most importantly the delay allowed us to discuss matters with the family to ensure we were doing the right thing by this elderly patient ! It made me reflect on a deeper issue that Scott and others raised a while ago and has been a silent undercurrent to the FOAMEd movement. How does one learn somethings that your peers and supervisors are clearly not supporting, not aware of nor interested in learning? Respiratory failure is common, as it occurs in any severe lung disease – it can also occur as a part of multi-organ failure. Causes of Type I respiratory failure: disease that damage lung tissue, including pulmonary oedema, pneumonia, acute respiratory distress syndrome, and chronic pulmonary fibrosing alveoloitis. Blood gas analysis – blood gas measurements are required for diagnosis of respiratory failure by definition (see Disease Site). Pulse oximetry – a light clip placed on the finger or earlobe gives a measure of blood oxygen saturation. Finally, if the above measures are not effective, some form of respiratory support needs to be considered.
Non-invasive techniques are used in conscious, cooperative patients, and are administered via face mask or nasal prongs. About myVMCVirtual Medical Centre is Australia’s leading source for trustworthy medical information written by health professionals based on Australian guidelines. Please be aware that we do not give advice on your individual medical condition, if you want advice please see your treating physician.
Type 1 diabetes is a chronic illness characterized by the bodya€™s inability to produce insulin due to the autoimmune destruction of the beta cells in the pancreas.
Blood glucose tests using capillary blood samples, reagent sticks, and blood glucose meters are the usual methods for monitoring day-to-day diabetes control.
Measurement of HbA1c levels is the best method for medium-term to long-term diabetic control monitoring. The aim of dietary management is to balance the child's food intake with insulin dose and activity and to keep blood glucose concentrations as close as possible to reference ranges, avoiding extremes of hyperglycemia and hypoglycemia. Most pediatric patients with diabetes have type 1 diabetes mellitus (T1DM) and a lifetime dependence on exogenous insulin. Type 2 diabetes mellitus (nona€“insulin-dependent diabetes mellitus [NIDDM]) is a heterogeneous disorder. Hypoglycemia is probably the most disliked and feared complication of diabetes, from the point of view of the child and the family. Manage mild hypoglycemia by giving rapidly absorbed oral carbohydrate or glucose; for a comatose patient, administer an intramuscular injection of the hormone glucagon, which stimulates the release of liver glycogen and releases glucose into the circulation. Occasionally, a child with hypoglycemic coma may not recover within 10 minutes, despite appropriate therapy. Hypoglycemia was a particular concern in children younger than 4 years because the condition was thought to lead to possible intellectual impairment later in life. Diabetic ketoacidosis (DKA) is much less common than hypoglycemia but is potentially far more serious, creating a life-threatening medical emergency.
If children persistently inject their insulin into the same area, subcutaneous tissue swelling may develop, causing unsightly lumps and adversely affecting insulin absorption.
The most common cause of acquired blindness in many developed nations, diabetic retinopathy is rare in the prepubertal child or within 5 years of onset of diabetes. In a patient with nephropathy, the albumin excretion rate (AER) increases until frank proteinuria develops, and this may progress to renal failure.
Progression may be delayed or halted by improved diabetes control, administration of angiotensin-converting enzyme inhibitors (ACE inhibitors), and aggressive blood pressure control.
A child younger than 15 years with persistent proteinuria may have a nondiabetic cause and should be referred to a pediatric nephrologist for further assessment. Autonomic changes involving cardiovascular control (eg, heart rate, postural responses) have been described in as many as 40% of children with diabetes. Gastroparesis is another complication, and it which may be caused by autonomic dysfunction. Although this complication is not seen in pediatric patients, it is a significant cause of morbidity and premature mortality in adults with diabetes. The combination of peripheral vascular disease and peripheral neuropathy can cause serious foot pathology. Although Addison disease is uncommon, affecting less than 1% of children with diabetes, it is a life-threatening condition that is easily missed.
Originally described in approximately 30% of patients with type 1 diabetes mellitus, limited joint mobility occurs in 50% of patients older than age 10 years who have had diabetes for longer than 5 years. Limited joint mobility is associated with increased risks for diabetic retinopathy and nephropathy. The glucose level at which symptoms develop varies greatly from individual to individual (and from time to time in the same individual), depending in part on the duration of diabetes, the frequency of hypoglycemic episodes, the rate of fall of glycemia, and overall control.
Most cases (95%) of type 1 diabetes mellitus are the result of environmental factors interacting with a genetically susceptible person. The frequency of diabetes development in children with a mother who has diabetes is 2-3%; this figure increases to 5-6% for children with a father who has type 1 diabetes mellitus. Human leukocyte antigen (HLA) class II molecules DR3 and DR4 are associated strongly with type 1 diabetes mellitus.
Patients expressing DR3 are also at risk for developing other autoimmune endocrinopathies and celiac disease. Patients expressing DR4 are usually younger at diagnosis and more likely to have positive insulin antibodies, yet they are unlikely to have other autoimmune endocrinopathies. Environmental factors are important, because even identical twins have only a 30-60% concordance for type 1 diabetes mellitus and because incidence rates vary in genetically similar populations under different living conditions.[19] No single factor has been identified, but infections and diet are considered the 2 most likely environmental candidates. Viral infections may be the most important environmental factor in the development of type 1 diabetes mellitus,[20] probably by initiating or modifying an autoimmune process.
Nitrosamines, chemicals found in smoked foods and some water supplies, are known to cause type 1 diabetes mellitus in animal models; however, no definite link has been made with humans. The known association of increasing incidence of type 1 diabetes mellitus with distance from the equator may now have an explanation.
Streptozotocin and RH-787, a rat poison, selectively damages islet cells and can cause type 1 diabetes mellitus. The overall annual incidence of diabetes mellitus is about 24.3 cases per 100,000 person-years. A population-based, nationwide cohort study in Finland examined the short -and long-term time trends in mortality among patients with early-onset and late-onset type 1 diabetes. Different environmental effects on type 1 diabetes mellitus development complicate the influence of race, but racial differences are evident.
Type 1 diabetes mellitus can occur at any age, but incidence rates generally increase with age until midpuberty and then decline.[26] Onset in the first year of life, although unusual, can occur, so type 1 diabetes mellitus must be considered in any infant or toddler, because these children have the greatest risk for mortality if diagnosis is delayed. Apart from severe DKA or hypoglycemia, type 1 diabetes mellitus has little immediate morbidity.
Information on mortality rates for type 1 diabetes mellitus is difficult to ascertain without complete national registers of childhood diabetes, although age-specific mortality is probably double that of the general population.[29, 30] Children aged 1-4 years are particularly at risk and may die due to DKA at the time of diagnosis.
The complications of type 1 diabetes mellitus can be divided into 3 major categories: acute complications, long-term complications, and complications caused by associated autoimmune diseases. Acute complications, which include hypoglycemia, hyperglycemia, and DKA, reflect the difficulties of maintaining a balance between insulin therapy, dietary intake, and exercise. Long-term complications arise from the damaging effects of prolonged hyperglycemia and other metabolic consequences of insulin deficiency on various tissues. Associated autoimmune diseases are common in type 1 diabetes mellitus, particularly in children who have HLA-DR3. Medscape's clinical reference is the most authoritative and accessible point-of-care medical reference for physicians and healthcare professionals, available online and via all major mobile devices.
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Medscape Reference features 129 medical calculators covering formulas, scales, and classifications. Hundreds of image-rich slideshow presentations visually engage and challenge readers while expanding their knowledge of both common and uncommon diseases, case presentations, and current controversies in medicine. Click on citations within drug and disease topics in our clinical reference to review the clinical evidence on MEDLINE. Medscape is the leading online destination for healthcare professionals seeking clinical information. Science, Technology and Medicine open access publisher.Publish, read and share novel research. Mental status changes can be seen with mild-to-moderate DKA; more severe deterioration in mental status is typical with moderate-to-severe DKA. Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome after renal transplantation in the United States.
Impact of admission hyperglycemia on stroke outcome after thrombolysis: risk stratification in relation to time to reperfusion. Mechanisms Determining Course and Outcome of Diabetic Patients Who Have Had Acute Myocardial Infarction. Acute myocardial infarction in a 12-year-old as a complication of hyperosmolar diabetic ketoacidosis. Diabetic ketoacidosis in the dialysis-dependent patient: two case reports and recommendations for treatment.
Adult respiratory distress syndrome complicating severely uncontrolled diabetes mellitus: report of nine cases and a review of the literature. Effect of hyperglycemia on reperfusion-associated recovery of intracellular pH and high energy phosphates after transient cerebral ischemia in gerbils. All content on this website, including dictionary, thesaurus, literature, geography, and other reference data is for informational purposes only. Another characteristic of concept maps is that the concepts are represented in a hierarchical fashion with the most inclusive, most general concepts at the top of the map and the more specific, less general concepts arranged hierarchically below. A final feature that may be added to concept maps is specific examples of events or objects that help to clarify the meaning of a given concept.
Concept maps were developed in 1972 in the course of Novaka€™s research program at Cornell where he sought to follow and understand changes in childrena€™s knowledge of science (Novak & Musonda, 1991).
In addition to the distinction between the discovery learning process, where the attributes of concepts are identified autonomously by the learner, and the reception learning process, where attributes of concepts are described using language and transmitted to the learner, Ausubel made the very important distinction between rote learning and meaningful learning. The material to be learned must be conceptually clear and presented with language and examples relatable to the learnera€™s prior knowledge. As noted above, it is important to recognize that because individuals vary in the quantity and quality of the relevant knowledge they possess, and in the strength of their motivation to seek ways to incorporate new knowledge into relevant knowledge they already possess, the rote-meaningful distinction is not a simple dichotomy but rather a continuum. Another important advance in our understanding of learning is that the human memory is not a single a€?vessela€? to be filled, but rather a complex set of interrelated memory systems.
While all memory systems are interdependent (and have information going in both directions), the most critical memory systems for incorporating knowledge into long-term memory are the short-term and a€?working memory.a€? All incoming information is organized and processed in the working memory by interaction with knowledge in long-term memory. This means that relationships among two or three concepts are about the limit of working memorya€™s processing capacity. It should be noted that retention of information learned by rote still takes place in long term memory, as does information learned meaningfully; the difference is that in rote learning, there is little or no integration of new knowledge with existing knowledge resulting in two negative consequences. Therefore, to structure large bodies of knowledge requires an orderly sequence of iterations between working memory and long-term memory as new knowledge is being received and processed (Anderson, 1992). There are obvious differences between individuala€™s abilities, and some of these have been explored by Gardner (1983). While it is true that some students have difficulty building concept maps and using these, at least early in their experience, this appears to result primarily from years of rote-mode learning practice in school settings rather than as a result of brain structure differences per se. To illustrate how difficult it can be for individuals to modify their ideas, especially if they learn primarily by rote, we cite the example of interviews done by the Private Universe Project (PUP) at Harvard University (Schneps, 1989). As indicated earlier, we defined concept as a perceived regularity (or pattern) in events or objects, or records of events or objects, designated by label. As defined above, concepts and propositions are the building blocks for knowledge in any domain. While there is value in studying more extensively the process of human learning and human knowledge creation, this is beyond the scope of this document. In learning to construct a concept map, it is important to begin with a domain of knowledge that is very familiar to the person constructing the map. A good way to define the context for a concept map is to construct a Focus Question, that is, a question that clearly specifies the problem or issue the concept map should help to resolve. Given a selected domain and a defined question or problem in this domain, the next step is to identify the key concepts that apply to this domain.
It is important to help students recognize that all concepts are in some way related to one another. Students often comment that it is hard to add linking words onto the a€?linesa€? of their concept map. Finally, the map should be revised, concepts re-positioned in ways that lend to clarity and better over-all structure, and a a€?finala€? map prepared. Thus, we see that concept maps are not only a powerful tool for capturing, representing, and archiving knowledge of individuals, but also a powerful tool to create new knowledge.
The software allows the user to link resources (photos, images, graphs, videos, charts, tables, texts, WWW pages or other concept maps) located anywhere on the Internet or in personal files to concepts or linking words in a concept map through a simple drag-and-drop operation. CmapTools provides extensive support for collaborative work during concept map construction. Through the storing of concept maps in CmapServers, CmapTools encourages collaboration among users constructing the maps.
The extensive support that CmapTools provides for the collaborative construction of concept maps by groups, whether they are at the same location or in distant locations, has encouraged the increasing use of collaboration during map building. A Concept Map-Centered Learning Environment CmapTools provides a variety of features that make it possible for teachers to use concept maps for a variety of the tasks that students perform (CaA±as & Novak, 2005). A concept map-centered learning environment implies that concept maps are used throughout the development of a learning unit or module. Just as there are many possible uses of concept maps within the classroom activities, there are a variety of a€?starting pointsa€? for the construction of the initial concept maps by students. Each student can construct the initial concept map individually, giving the teacher feedback on the level of understanding of every student. The concept map can also be a class effort, using a projector, where all students give their opinion and participate in the construction of the map.
Likewise, the starting point from which the map is constructed can vary depending on the expected previous understanding by the students, the difficulty and novelty of the topic, and the teachera€™s confidence in mastering the topic. We refer to a list of concept waiting to be added to a concept map as the parking lot of concepts. Figure 11 is an a€?expert skeletona€? concept map that corresponds to the same topic as the a€?parking lota€? in Figure 10. The use of a€?expert skeletona€? concept maps is a research topic we are pursuing, and for which we dona€™t have as much experience as with the focus question and parking lot starting points. It is important to note that the a€?expert skeletona€? concept maps should be built by an expert on the topic. We foresee a program of using a€?expert skeletona€? maps to scaffold learning beginning with the development of a series of concept maps in a discipline, starting with the most general, most inclusive ideas and then gradually moving to more specific concept maps that will guide the learners.
Learners can also engage in laboratory or field studies that will add important concrete experiences needed for developing fuller meanings to concepts, and sometimes the excitement that comes with discovering new ideas or relationships. The extent of materials and ideas that can be built into knowledge structures using a€?expert skeletona€? concept maps, CmapTools, and WWW resources far surpass what any textbook or any teacher could provide. In 1966, Bobbs-Merrill published an elementary science textbook series, The World of Science, written largely by Novak with the objective of introducing basic science concepts to elementary school students and teachers. Obviously, it would be a very deficient science program that did nothing more than have students copy and do some building on the a€?expert skeletona€? concept maps provided for grade two, or for any other grade. A pilot program effort is already in progress in Italy, where Giuseppe Valittuti (2004) and his colleagues are now working to translate The World of Science books into Italian. The greatest challenge we may expect is to change the school situational factors in the direction of teacher as coach and learner from the prevailing model of teachers as disseminator of information.
We might expect some oppositioin to implementation of the New Model of Education from individuals who believe that "inquiry" learningis the only way to improve education. There is an enormous job of teacher education that needs to be done before the New Model can be implemented in schools. We are now beginning to see in many science textbooks the inclusion of concept mapping as one way to summarize understandings acquired by students after they study a unit or chapter. Using concept maps in planning a curriculum or instruction on a specific topic helps to make the instruction a€?conceptually transparenta€? to students.
One of the uses of concept maps that is growing at a fast rate is the use of concept maps to capture the a€?tacita€? knowledge of experts. While we expect that interviews, case study analyses, a€?critical incidenta€? analyses and similar techniques will have value in extracting and representing expert knowledge, it is likely that the end product of these studies might still be best represented in the form of concept maps, perhaps with some of the interview data and other information presented through icons on maps. At IHMC we continue to be very active in the area of capturing and representing expert knowledge (Coffey et al., 2002). In this paper we have tried to present the theoretical foundations and the origins of what we call concept maps. We also wish to use this document as a foundation for further experimentation, critique, and dialogue regarding the use of this tool.
She is promptly rushed into the resus bay in extremis with cyanosis & poor respiratory effort. Neither of us had had formal teaching on such a scenario, but the application of various lessons (EGDT, DSI, apnoeic oxygenation) served us well on the night & truly made a difference to this patients outcome !! The respiratory system basically consists of a gas exchanging organ (the lungs) and a ventilatory pump (respiratory muscles and the thorax). Causes of Type II respiratory failure: the most common cause is chronic obstructive pulmonary disease (COPD).
This lung damage prevents adequate oxygenation of the blood (hypoxaemia); however, the remaining normal lung is still sufficient to excrete the carbon dioxide being produced by tissue metabolism. It occurs when alveolar ventilation is insufficient to excrete the carbon dioxide being produced. They are especially useful to monitor progress in patients with respiratory inadequacy due to neuromuscluar problems, such as Guillain-Barre syndrome, in which the vital capacity decreases as the weakness increases. This is not as reliable as arterial blood gas analysis, but is much easier and gives a continuous reading. Patients can be given supplemental oxygen, and mechanically ventilated if needed – although long-term ventilation has significant consequences. There are many different devices and techniques used in providing respiratory support; they will not be discussed in detail. Most pediatric patients with diabetes have type 1 and a lifetime dependence on exogenous insulin. Most require 2 or more injections of insulin daily, with doses adjusted on the basis of self-monitoring of blood glucose levels. Diabetes mellitus (DM) is a chronic metabolic disorder caused by an absolute or relative deficiency of insulin, an anabolic hormone. Most patients with type 2 diabetes mellitus have insulin resistance, and their beta cells lack the ability to overcome this resistance.[5] Although this form of diabetes was previously uncommon in children, in some countries, 20% or more of new patients with diabetes in childhood and adolescence have type 2 diabetes mellitus, a change associated with increased rates of obesity.
Children hate the symptoms of a hypoglycemic episode and the loss of personal control it may cause. Where appropriate, an alternative therapy is intravenous glucose (preferably no more than a 10% glucose solution). Under no circumstances should further treatment be given, especially intravenous glucose, until the blood glucose level is checked and still found to be subnormal. In a child with diabetes, blood sugar levels rise if insulin is insufficient for a given glucose load.
Users of insulin pumps, by virtue of absent reservoirs of subcutaneous insulin, may present with ketosis and more normal blood glucose levels. The prevalence and severity of retinopathy increase with age and are greatest in patients whose diabetic control is poor. Blood pressure rises with increased AER, and hypertension accelerates the progression to renal failure. Regular urine screening for microalbuminuria provides opportunities for early identification and treatment to prevent renal failure.
Hyperglycemic effects on axons and microvascular changes in endoneural capillaries are amongst the proposed mechanisms. Cardiovascular control changes become more likely with increasing duration and worsening control.[14] In adults, peripheral neuropathy usually occurs as a distal sensory loss.
Gastric emptying is significantly delayed, leading to problems of bloating and unpredictable excursions of blood glucose levels.
People with type 1 diabetes mellitus have twice the risk of fatal myocardial infarction (MI) and stroke that people unaffected with diabetes do; in women, the MI risk is 4 times greater. Smoking, hypertension, hyperlipidemia, and poor diabetic control greatly increase the risk of vascular disease.
Addison disease may reduce the insulin requirement and increase the frequency of hypoglycemia. The condition restricts joint extension, making it difficult to press the hands flat against each other. Improved diabetes control over the past several years appears to have reduced the frequency of these additional complications by a factor of approximately 4. Insulin reduces blood glucose levels by allowing glucose to enter muscle cells and by stimulating the conversion of glucose to glycogen (glycogenesis) as a carbohydrate store. The kidneys cannot reabsorb the excess glucose load, causing glycosuria, osmotic diuresis, thirst, and dehydration.
This interaction leads to the development of autoimmune disease directed at the insulin-producing cells of the pancreatic islets of Langerhans. Monozygotic twins have a 60% lifetime concordance for developing type 1 diabetes mellitus, although only 30% do so within 10 years after the first twin is diagnosed. More than 90% of whites with type 1 diabetes mellitus express 1 or both of these molecules, compared with 50-60% of the general population.
These patients are more likely to develop diabetes at a later age, to have positive islet cell antibodies, and to appear to have a longer period of residual islet cell function. The expression of both DR3 and DR4 carries the greatest risk of type 1 diabetes mellitus; these patients have characteristics of both the DR3 and DR4 groups. Breastfed infants have a lower risk for type 1 diabetes, and a direct relationship is observed between per capita cow's milk consumption and the incidence of diabetes.
Substantial variations are observed between nearby countries with differing lifestyles, such as Estonia and Finland, and between genetically similar populations, such as those in Iceland and Norway. The results suggest that in those with early-onset type 1 diabetes (age 0-14 y), survival has improved over time. These variations strongly support the importance of environmental factors in the development of type 1 diabetes mellitus. Males are at greater risk in regions of high incidence, particularly older males, whose incidence rates often show seasonal variation.
Frequency and timing of severe hypoglycemia affects spatial memory in children with type 1 diabetes.
A 3-19-year follow-up study on diabetic retinopathy in patients diagnosed in childhood and treated with conventional therapy. Development and progression of microalbuminuria in a clinic sample of patients with insulin dependent diabetes mellitus. The effect of subclinical hypothyroidism on metabolic control in children andadolescents with Type 1 diabetes mellitus. Occurrence of celiac disease after onset of type 1 diabetes: a 6-year prospectivelongitudinal study. Changes in frequency and severity of limited joint mobility in children withtype 1 diabetes mellitus between 1976-78 and 1998.
Activating mutations in the gene encoding the ATP-sensitive potassium-channel subunit Kir6.2 and permanent neonatal diabetes. Epidemiology of childhood IDDM in Northern Ireland 1989-1994: low incidence in areas with highest population density and most household crowding. A prospective study of the role of coxsackie B and other enterovirus infections in the pathogenesis of IDDM. The association between ultraviolet B irradiance, vitamin D status and incidence rates of type 1 diabetes in 51 regions worldwide.
Time trends in mortality in patients with type 1 diabetes: nationwide population based cohort study. Genetic interaction among three genomic regions creates distinct contributions to early- and late-onset type 1 diabetes mellitus.
The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.
Microvascular and macrovascular complications associated with diabetes in children and adolescents. Global standardization of glycated hemoglobin measurement: the position of the IFCC Working Group. Clinic-integrated behavioral intervention for families of youth with type 1 diabetes: randomized clinical trial. Routine hospital admission versus out-patient or home care in children at diagnosisof type 1 diabetes mellitus. Probiotic use in infancy and islet autoimmunity in The Environmental Determinants of Diabetes in the Young (TEDDY) study [abstract 170].
Association between diabetes control and visits to a multidisciplinary pediatric diabetes clinic. Care of children and adolescents with type 1 diabetes: a statement of the AmericanDiabetes Association. The delivery of ambulatory diabetes care: structures, processes, and outcomes of ambulatory diabetes care. Short acting insulin analogues versus regular human insulin in patients withdiabetes mellitus. Comparison of metabolic control in a cross-sectional study of 2,873 children and adolescents with IDDM from 18 countries. Persistent differences among centers over 3 years in glycemic control and hypoglycemiain a study of 3,805 children and adolescents with type 1 diabetes from the HvidA?A?re Study Group.
Cyclosporin increases the rate and length of remissions in insulin-dependent diabetes of recent onset. Immunotherapy for the prevention and treatment of type 1 diabetes: human trials and a look into the future. Disturbed Eating Behavior and Omission of Insulin in Adolescents Receiving Intensified Insulin Treatment: A nationwide population-based study. Thyroid function and autoimmunity in children and adolescents with Type 1 Diabetes Mellitus. Interventions for Diabetic Retinopathy in Type 1 Diabetes: Systematic Review and Meta-analysis.
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Haemoglobin saturation (SaO2) in diabetics and non-diabetics suffering AMI and in control groupTable 1. Tell a friend about us, add a link to this page, or visit the webmaster's page for free fun content. They include concepts, usually enclosed in circles or boxes of some type, and relationships between concepts indicated by a connecting line linking two concepts. The hierarchical structure for a particular domain of knowledge also depends on the context in which that knowledge is being applied or considered. These are relationships or links between concepts in different segments or domains of the concept map.

Normally these are not included in ovals or boxes, since they are specific events or objects and do not represent concepts.
During the course of this study the researchers interviewed many children, and they found it difficult to identify specific changes in the childrena€™s understanding of science concepts by examination of interview transcripts. These are acquired by children during the ages of birth to three years, when they recognize regularities in the world around them and begin to identify language labels or symbols for these regularities (Macnamara, 1982). Concept maps can be helpful to meet this condition, both by identifying large general concepts held by the learner prior to instruction on more specific concepts, and by assisting in the sequencing of learning tasks though progressively more explicit knowledge that can be anchored into developing conceptual frameworks. This condition can be met after age 3 for virtually any domain of subject matter, but it is necessary to be careful and explicit in building concept frameworks if one hopes to present detailed specific knowledge in any field in subsequent lessons.
The one condition over which the teacher or mentor has only indirect control is the motivation of students to choose to learn by attempting to incorporate new meanings into their prior knowledge, rather than simply memorizing concept definitions or propositional statements or computational procedures.
Creativity can be seen as a very high level of meaningful learning, and we will discuss this further. Both direct presentation and discovery teaching methods can lead to highly rote or highly meaningful learning by the learner, depending on the disposition of the learner and the organization of the instructional materials. The Rote-Meaningful learning continuum is not the same as the Reception-Discovery instructional continuum. Concept maps are also effective in identifying both valid and invalid ideas held by students, and this will be discussed further in another section.
Figure 4 illustrates the memory systems of the human mind, and interactions with inputs from our affective and psychomotor inputs.
The limiting feature here is that working memory can process only a relatively small number of psychological units (five to nine) at any one moment (Miller, 1956). For example, if a person is presented with a list of 10-12 letters or numbers to memorize in a few seconds, most will recall only 5 to 9 of these.
We believe one of the reasons concept mapping is so powerful for the facilitation of meaningful learning is that it serves as a kind of template or scaffold to help to organize knowledge and to structure it, even though the structure must be built up piece by piece with small units of interacting concept and propositional frameworks. While the latter are the principal elements that make up our knowledge structures and form our cognitive structure in the brain, we pause briefly to discuss other forms of learning. So-called a€?learning stylea€? differences are, to a large extent, derivative from differences in the patterns of learning that students have employed varying from high commitment to continuous rote-mode learning to almost exclusive commitment to meaningful mode learning. The staff of PUP interviewed 23 Harvard graduates, alumni and faculty, asking each a€?Why do we have seasons?a€? Only eleven concepts, properly organized are needed to understand why we have seasons, and one arrangement of these concepts is shown in Figure 5. One representation of the knowledge structure required required for understanding why we have seasons.
It is coming to be generally recognized now that the meaningful learning processes described above are the same processes used by scientists and mathematicians, or experts in any discipline, to construct new knowledge.
We can use the analogy that concepts are like the atoms of matter and propositions are like the molecules of matter. Since concept map structures are dependent on the context in which they will be used, it is best to identify a segment of a text, a laboratory or field activity, or a particular problem or question that one is trying to understand. Every concept map responds to a focus question, and a good focus question can lead to a much richer concept map.
These are links between concepts in different segments or domains of knowledge on the map that help to illustrate how these domains are related to one another. A a€?stringa€? map created by a fourth grade student following a class field trip to a paper mill.
Therefore, it is necessary to be selective in identifying cross-links, and to be as precise as possible in identifying linking words that connect concepts. This is because they poorly understand the relationship between the concepts, or the meanings of the concepts, and it is the linking words that specify this relationship. When computer software is used, one can go back, change the size and font style, and add colors to a€?dress upa€? the concept map. The software not only makes it easy for users of all ages to construct and modify concept maps in a similar way that a word processor makes it easy to write text, it allows users to collaborate at a distance in the construction in their maps, publish their concept maps so anybody on the Internet can access them, link resources to their maps to further explain their contents, and search the WWW for information related to the map. Links to these resources are displayed as icons underneath the concepts, as shown in Figure 7. Vygotsky (1978) introduced the idea that language and social dialogue can support learning, especially when members of the social group are at about the same Zone of Proximal Development (ZPD).
When maps are stored in a server on the Internet, users with appropriate permissions (CaA±as et al., 2003c) can edit shared concept maps at the same time (synchronously) or at their convenience (asynchronously). Concept maps within this environment are likely to be used as the mechanism to determine the level of understanding students have about the topic being studied before the topic is introduced. The whole spectrum of learning activities can be integrated using CmapTools, incorporating various learning activities recorded via the software creating a digital portfolio as a product of the learning.
For example, a€?How do we measure time?a€? can be given to the students as the question to answer through the construction of the concept map. The staring point for the construction of the concept map can be a list of concepts that the teacher wants to make sure all students include in their map. The beginning of a concept map with a focus question and a parking lot with concepts to be included in the map.
An a€?expert skeletona€? concept map has been previously prepared by an expert on the topic, and permits both students and teachers to build their knowledge on a solid foundation. Observe that in this example, some of the concepts were left in the a€?parking lota€? for the student to add to the concept map. Oa€™Donnell, Dansereau, & Hall (2002) have shown that a€?knowledge mapsa€? can act as scaffolds to facilitate learning. The intention is that the expert will be better at selecting the small number of concepts that are key to understanding the topic, and express accurately the relationships between these concepts. But the expected final number of concepts in the map is a function of the number of concepts in the a€?skeletona€?.
For example, Figure 11 shows a a€?expert skeletona€? concept map for the sciences that encompasses key major concepts needed to understand science. An Energy transformation Cmap that could be accessed by linking it to the a€?Energya€? concept in the concept map in Figure 11, and a Photosynthesis Cmap that may be linked to it.
Thus if one clicks on a concept such as a€?electrical energya€? in Figure 12 and selects one of the a€?searcha€? menu options, CmapTools will retrieve WWW resources that not only deal with electricity, but also relate to other concepts in the map. In fact, teachers supervising this kind of study are likely to learn as many new things as their students. Unlike most elementary science textbooks, this series presents in-depth instruction in basic concepts at all grade levels, including instruction in concepts dealing with the nature of science, nature of matter, energy and energy transformations. Schema showing the New Model for Education with an a€?expert skeletona€? concept map that can serve as the a€?backbonea€? for an emerging portfolio in science.
It would be important for the teacher to help students perform these activities, and similar related activities, some of which might by suggested in WWW resources.
Schema showing the New Model for Education with concepts and resources added to the a€?expert skeletona€? concept map, plus a page from a World of Science book providing relevant reading and activities.
Students need concrete, hands on experiences with real things and to observe real phenomena to put meaning into the concept labels provided in the concept maps and other resources.
Valittuti and his colleagues have obtained funding from the Italian Ministry of Education for teacher training and a number of elementary school teams began working with the World of Science concept maps and other resources during the 2005-2006 year. We know that we need to engage teachers and administrators in training programs that can model the new educational approaches, and we need to seek their counsel on ways to improve on the New Model for Education.
Teachers need to become familiar with the use of CmapTools software and the various tools it contains. Change in school practices is always slow, but it is likely that the use of concept maps in school instruction will increase substantially in the next decade or two. Many students have difficulty identifying the important concepts in a text, lecture or other form of presentation.
A concept map prepared cooperatively by the faculty of the College of Veterinary Medicine at Cornell University to show the over-all structure for a revised curriculum. In fact, these methods continue to be highly popular with many cognitive scientists, most of whom are unfamiliar with Ausubela€™s work and the kind of epistemological ideas on which concept mapping is based. As the CmapTools software has evolved, it has become an increasingly useful tool for this work, as illustrated by the remarkable resources on Mars prepared at NASA Amesa€™ Center for Mars Exploration (Briggs et al., 2004). An example of a concept map that can be accessed via clicking on one of the resources attached to a concept on Figure 16.
While at first glance concept maps may appear to be just another graphic representation of information, understanding the foundations for this tool and its proper use will lead the user to see that this is truly a profound and powerful tool. The CmapTools web site provides opportunities for lively exchanges among users and researchers. This is possible because less functioning lung tissue is required for carbon dioxide excretion than is needed for oxygenation of the blood. Inadequate ventilation is due to reduced ventilatory effort, or inability to overcome increased resistance to ventilation – it affects the lung as a whole, and thus carbon dioxide accumulates.
In addition, blood gas analysis enables disturbances in acid-base balance (acidosis or alkalosis) to be identified. Broadly speaking, respiratory support techniques can be split into non-invasive and invasive techniques. Respiratory support also weakens the respiratory muscles, so spontaneous respiration has to be resumed gradually. Insulin replacement is accomplished by giving a basal insulin and a preprandial (premeal) insulin.
Insulin is produced by the beta cells of the islets of Langerhans located in the pancreas, and the absence, destruction, or other loss of these cells results in type 1 diabetes (insulin-dependent diabetes mellitus [IDDM]). Other patients may have inherited disorders of insulin release, leading to maturity onset diabetes of the young (MODY) or congenital diabetes.[6, 7, 8] This topic addresses only type 1 diabetes mellitus.
In the absence of insulin, however, severe hyperglycemia, dehydration, and ketone production contribute to the development of DKA.
They are more likely to present with nausea, vomiting, and abdominal pain, symptoms similar to food poisoning.
Necrobiosis lipoidica affects 1-2% of children and may be more common in children with poor diabetic control.
Insulin also inhibits the release of stored glucose from liver glycogen (glycogenolysis) and slows the breakdown of fat to triglycerides, free fatty acids, and ketones.
If insulin is injected into a treated child with diabetes who has not eaten adequate amounts of carbohydrates, blood glucose levels progressively fall. These cells are progressively destroyed, with insulin deficiency usually developing after the destruction of 90% of islet cells.
In contrast, dizygotic twins have only an 8% risk of concordance, which is similar to the risk among other siblings. One survey suggests enteroviral infection during pregnancy carries an increased risk of type 1 diabetes mellitus in the offspring.
Some cow's milk proteins (eg, bovine serum albumin) have antigenic similarities to an islet cell antigen. Survival of those with late-onset type 1 diabetes (15-29 y) has deteriorated since the 1980s, and the ratio of deaths caused by acute complications has increased in this group.
Type 1 diabetes mellitus is 1.5 times more likely to develop in American whites than in American blacks or Hispanics.
Most deaths result from delayed diagnosis or neglected treatment and subsequent cerebral edema during treatment for DKA, although untreated hypoglycemia also causes some deaths. Debbie Matthews, Colleagues at the Royal Victoria Infirmary, Newcastle upon Tyne, for reading through the manuscript and for years of support. Customize your Medscape account with the health plans you accept, so that the information you need is saved and ready every time you look up a drug on our site or in the Medscape app.
IntroductionDiabetic ketoacidosis (DKA) is considered a predominantly acute type 1 diabetic complication, although it may occur in type 2 diabetes as well, particularly in patients who already have a decreased insulin secretion capacity. Although true lactic acidosis occurs rarely, the increased lactate load may further contribute to the degree of acidosis. Moreover, pH, bicarbonate and anion gap are not routinely monitored in all diabetic patients suffering stroke, at least not in secondary level health institutions worldwide.
Words on the line, referred to as linking words or linking phrases, specify the relationship between the two concepts. Therefore, it is best to construct concept maps with reference to some particular question we seek to answer, which we have called a focus question. Cross-links help us see how a concept in one domain of knowledge represented on the map is related to a concept in another domain shown on the map. This early learning of concepts is primarily a discovery learning process, where the individual discerns patterns or regularities in events or objects and recognizes these as the same regularities labeled by older persons with words or symbols.
The indirect control over this choice is primarily in instructional strategies used and the evaluation strategies used. They can be as effective as more time-consuming clinical interviews for identifying the relevant knowledge a learner possesses before or after instruction (Edwards & Fraser, 1983). However, if the letters can be grouped to form a know word, or word-like unit, or the numbers can be related to a phone number or something known, then 10 or more letters or numbers can be recalled. Second, the knowledge structure or cognitive structure of the learner is not enhanced or modified to clear up faulty ideas. Iconic learning involves the storage of images of scenes we encounter, people we meet, photos, and a host of other images. His work has received much attention in education and has served to draw attention to the broad range of differences in human abilities for various kinds of learning and performance.
It is not easy to help students in the former condition move to patterns of learning of the latter type.
The PUP interviewers found that 21 of the 23 interviewed could not explain why we have seasons, a topic that is taught repeatedly in school.
In fact, Novak has argued that new knowledge creation is nothing more than a relatively high level of meaningful learning accomplished by individuals who have a well organized knowledge structure in the particular area of knowledge, and also a strong emotional commitment to persist in finding new meanings (Novak, 1977, 1993, 1998).
There are only around 100 different kinds of atoms, and these make up an infinite number of different kinds of molecules. Some important considerations for construction of better concept maps and facilitation of learning will be discussed further below. This creates a context that will help to determine the hierarchical structure of the concept map.
When learning to construct concept maps, learners tend to deviate from the focus question and build a concept map that may be related to the domain, but which does not answer the question. These concepts could be listed, and then from this list a rank ordered list should be established from the most general, most inclusive concept, for this particular problem or situation at the top of the list, to the most specific, least general concept at the bottom of the list. Post-its allow a group to work on a whiteboard or butcher paper and to move concepts around easily. Cross-links are important in order to show that the learner understands the relationships between the sub-domains in the map.
The class identified concepts in the parking lot on the left, but this student was not successful in using many of these and her map makes little sense. Cross-links are key to show that the learner understands the relationships between the sub-domains in the map. In addition, one should avoid a€?sentences in the boxesa€?, that is, full sentences used as concepts, since this usually indicates that a whole subsection of the map could be constructed from the statement in the box. Once students begin to focus-in on good linking words, and on the identification of good cross-links, they can see that every concept could be related to every other concept. Clicking on one of these icons will display a list of links from which the user can select to open the linked resource. Many of the CmapServers are a€?publica€?, allowing anybody (no authorization needed) to publish their collections of concept maps and resources (CaA±as et al., 2004a). Concept maps are now beginning to be used in corporations to help teams clarify and articulate the knowledge needed to solve problems ranging from the design of new products to marketing to administrative problem resolution. The concept map can thus become an artifact around which the various activities of the learning process can be centered, as shown in Figure 8. The maps are then developed, extended and refined as the students develop other activities on the topic and increase their understanding, possibly concluding with complex knowledge models that link resources, results, experiments, etc., and that can be used if desired as a final presentation by the students. The concept map can be constructed by students working in couples or small groups, where the teacher must pay attention to the level of participation of every student.
The list of propositions on the top right window are automatically derived from the Cmap, and those with a a€?pina€? have been a€?publisheda€?. The type of focus question makes a difference in the type of concept maps that the student builds.
For example, a a€?skeleton mapa€? that consists of five concepts should be expanded by the student to a map with 15 to 20 concepts.
Learners can begin with such a map, add concepts from the parking lot, link digital resources and also construct more specific submaps. The program tries to figure out what the Cmap is about and prepare a query for Web search engines that will generate results that are relevant to the ideas being developed in the concept map.
Moreover, beginning with the a€?expert skeletona€? maps as starting points reduces the chance that misconceptions or faulty ideas held by learners or teachers will be reinforced and maximize the chance that they will build knowledge structures that in time remove or diminish misconceptions (Novak, 2002). Learners would also add their own concepts to the a€?expert skeletona€? concept map, as well as resources identified in readings and from the Internet.
The plan is to have four sets of schools focus on different aspects of The World of Science series and produce photos and videos of students doing projects that illustrate and utilize the various science concepts.
There is also the challenge of changing assessment practices that now rely primarily on multiple-choice tests that measure mainly rote recall of information, to performance-based tests that require students to demonstrate that they understand basic concepts and can use these concepts in novel problems solving, and that they can use Internet resources to grow and modify their concepts and learn new concepts. They also need to learn about the theory underlying concept mapping, including the ideas in this paper. Other innovative practices for assessing student understanding of subject matter are also available (Mintzes et al., 2000).
The hierarchical organization of concept maps suggests more optimal sequencing of instructional material. Part of the problem stems from a pattern of learning that simply requires memorization of information, and no evaluation of the information is required. This tacit knowledge is acquired over years of experience and derives in part from activities of the expert that involve thinking, feeling and acting. We also used a€?clinical interviewsa€? in our early work, as noted above, but we found it necessary to invent a better way to represent what our learners knew and how their knowledge was changing over time.
Figure 16 shows a a€?Homea€? concept map for the knowledge portfolio that Briggs created and Figure 17 shows one of the many submaps he created.
It may at first look like a simple arrangement of words into a hierarchy, but when care is used in organizing the concepts represented by the words, and the propositions or ideas are formed with well-chosen linking words, one begins to see that a good concept map is at once simple, but also elegantly complex with profound meanings.
This document itself should be a a€?livinga€? document, with revisions occurring periodically as we gain new knowledge and experiences with the use of this tool. The effects of cooperative, competitive and individualistic goal structure on achievement: A meta-analysis. The information available in brief visual presentations, Psychological Monographs: General and Applied, 74(11), 1-30.
Respiratory failure occurs when gas echange at the lungs is sufficiently impaired to cause a drop in blood levels of oxgyen (hypoxaemia); this may occur with or without an increase in carbon dioxide levels.
Complications include: damage to vital organs due to hypoxaemia, CNS depression due to increased carbon dioxide levels, respiratory acidosis (carbon dioxide retention). Tracheostomy involves making an incision in the neck, and placing the tube directly into the trachea. The basal insulin is either long-acting (glargine or detemir) or intermediate-acting (NPH). The most serious complication of DKA is the development of cerebral edema, which increases the risk of death and long-term morbidity. Without insulin, a child with type 1 diabetes mellitus wastes away and eventually dies due to DKA. Paradoxically, type 1 diabetes mellitus incidence is higher in areas where the overall burden of infectious disease is lower. Current evidence suggests that when immigrants from an area with low incidence move to an area with higher incidence, their rates of type 1 diabetes mellitus tend to increase toward the higher level.
Easily compare tier status for drugs in the same class when considering an alternative drug for your patient. Additional 30% had a compensated metabolic acidosis with normal pH and mild to moderately decreased bicarbonate level.
Stress –induced burst in catecholamine and ACTH secretion in acute myocardial infarction (AMI) promotes release of free fatty acids and their hepatic and muscular tissue utilization. In conclusion, some of the DKA cases in patients with stroke may easily be overlooked.Furthermore, there is striking lack of literature data concerning management of adult diabetic patients with stroke.
We define concept as a perceived regularity in events or objects, or records of events or objects, designated by a label. The concept map may pertain to some situation or event that we are trying to understand through the organization of knowledge in the form of a concept map, thus providing the context for the concept map.
In the creation of new knowledge, cross-links often represent creative leaps on the part of the knowledge producer.
The fundamental idea in Ausubela€™s cognitive psychology is that learning takes place by the assimilation of new concepts and propositions into existing concept and propositional frameworks held by the learner. This is a phenomenal ability that is part of the evolutionary heritage of all normal human beings.
Instructional strategies that emphasize relating new knowledge to the learnera€™s existing knowledge foster meaningful learning. In a related test, if we give learners 10-12 familiar but unrelated words to memorize in a few seconds, most will recall only 5-9 words.
It is good that schools are recognizing that there are important human capabilities other than the recall of specific cognitive information so often the only form of learning represented in multiple-choice tests used commonly in schools and corporations.
While concept maps can help, students also need to be taught something about brain mechanisms and knowledge organization, and this instruction should accompany the use of concept maps.
Included in this group was a graduate who had recently taken a course in the Physics of Planetary Motion, who also believed erroneously that seasons were caused by the earth moving closer to the sun in summer and further away in the winter.
Epistemology is that branch of philosophy that deals with the nature of knowledge and new knowledge creation.
There are now about 460,000 words in the English language (most of which are concept labels), and these can be combined to form an infinite number of propositions. It is often stated that the first step to learning about something is to ask the right questions. Although this rank order may be only approximate, it helps to begin the process of map construction. This is necessary as one begins to struggle with the process of building a good hierarchical organization.
This student was a good oral reader, but she had very poor reading comprehension and was a committed rote learner (see Novak & Gowin, 1984, page 108).
This also produces some frustration, and they must choose to identify the most prominent and most useful cross-links. Using CmapTools, it is possible to use concept maps to access any material that can be presented digitally, including materials prepared by the mapmaker. When students work cooperatively in groups and use concept maps to guide their learning, significantly greater learning occurs (Preszler, 2004). Through CmapServers, users of all ages and working in many disciplines have published thousands of maps on all topics and domains. The high degree of explicitness of concept maps makes them an ideal vehicle for exchange of ideas or for the collaborative construction of new knowledge. CmapTools has a recorder feature tht allows recording and playback of steps in map construction, including identification of each contributor. The lower right window shows propositions from other participants in Soup, some of which have discussion threads attached questioning or commenting on the proposition.
A question like a€?What are plants?a€? will lead to a declarative, more classificatory concept map than the question a€?Why do we need plants?a€? Experiments show that not only the focus question, but also the root concept of a concept map have a strong influence on the quality of the resulting concept map (Derbentseva et al., 2004, 2006).
Figure 10 presents the focus question and parking lot for the focus question a€?What is the structure of the Universe?a€? The student, group of students, or class is expected to build a concept map that answers the question and includes at least the concepts in the list. If the a€?skeletona€? map contains 20 concepts, which makes it more of a complete map, the final map could be expected to contain about 50 to 60 concepts. Of course, the learner still needs to select new concepts from the material and construct new propositions on the concept map that add meanings and clarity to the map. Our plan is to use The World of Science books as a starting point for a demonstration project for A New Model for Education. There will be much feedback from classrooms helping the teams to refine their work, sharing a€?electronic portfoliosa€? using CmapTools.
There remains in the New Model plenty of room for acquisition of specific facts and procedures, but now these should be learned within the context of powerful conceptual frameworks.
Since the fundamental characteristic of meaningful learning is integration of new knowledge with the learnersa€™ previous concept and propositional frameworks, proceeding from the more general, more inclusive concepts to the more specific information usually serves to encourage and enhance meaningful learning. Such students fail to construct powerful concept and propositional frameworks, leading them to see learning as a blur of myriad facts, dates, names, equations, or procedural rules to be memorized.
Concept mapping has been shown to help learners learn, researchers create new knowledge, administrators to better structure and manage organizations, writers to write, and evaluators assess learning. Some interrelationships between constructivist models of learning and current neurobiological theory, with implications for science education. Alternative instructional systems and the development of problem solving skills in physics.
Experiments on the effect of map structure and concept quantification during concept map construction.
The magical number seven, plus or minus two: Some limits on our capacity for processing information. Concept maps and vee diagrams: Two metacognitive tools for science and mathematics education. Human constructivism: A unification of psychological and epistemological phenomena in meaning making. Learning, creating, and using knowledge: Concept maps as facilitative tools in schools and corporations. Meaningful learning: The essential factor for conceptual change in limited or appropriate propositional hierarchies (liphs) leading to empowerment of learners. The preprandial insulin is either rapid-acting (lispro, aspart, or glulisine) or short-acting (regular).
Very young children at the time of first diagnosis are most likely to develop cerebral edema. Additionally, insulin inhibits the breakdown of protein and fat for glucose production (gluconeogenesis) in the liver and kidneys.
The pH was normalized at a price of the increased respiratory effort to lower the PaCO2 which may lead to respiratory muscle fatigue. The impairment in insulin-mediated intracellular glucose influx owing to the absent or insufficient pancreatic insulin secretion is the prerequisite for the occurrence of diabetic ketoacidosis. Although there are clear concerns about the volume overload, intensive use of osmotic and Henley’s loop diuretics and the need for careful volume and monitoring in patients suffering cerebrovascular accident and DKA no clear guidelines were produced for intensive care units and intensive care neurologic units.
The label for most concepts is a word, although sometimes we use symbols such as + or %, and sometimes more than one word is used. There are two features of concept maps that are important in the facilitation of creative thinking: the hierarchical structure that is represented in a good map and the ability to search for and characterize new cross-links. This knowledge structure as held by a learner is also referred to as the individuala€™s cognitive structure. After age 3, new concept and propositional learning is mediated heavily by language, and takes place primarily by a reception learning process where new meanings are obtained by asking questions and getting clarification of relationships between old concepts and propositions and new concepts and propositions. Evaluation strategies that encourage learners to relate ideas they possess with new ideas also encourage meaningful learning. The reality is that unless students possess at least a rudimentary conceptual understanding of the phenomenon they are investigating, the activity may lead to little or no gain in their relevant knowledge and may be little more than busy work.
If the words are unfamiliar, such as technical terms introduced for the first time, the learner may do well to recall correctly two or three of these. While the alphanumeric images Sperling used in his studies were quickly forgotten, other kinds of images are retained much longer. Studies by Penfield and Perot (1963), among others, indicate that regions of our brain that are activated when we hear sounds are the same regions that are active when we recall sounds. One reason we encourage the integration of the broad range of activities represented in our New Model for Education is to provide opportunities for these other abilities to be represented and expressed. The information in the above paragraphs should become part on the instructional program for skillful use of concept maps.
In fact, the earth is slightly closer to the sun when it is winter in Massachusetts, rather than in summer.
There is an important relationship between the psychology of learning, as we understand it today, and the growing consensus among philosophers and epistemologists that new knowledge creation is a constructive process involving both our knowledge and our emotions or the drive to create new meanings and new ways to represent these meanings.
Although most combinations of words might be nonsense, there is still the possibility of creating an infinite number of valid and meaningful propositions.
We refer to the list of concepts as a parking lot, since we will move these concepts into the concept map as we determine where they fit in. Computer software programs are even better in that they allow moving of concepts together with linking statements and the moving of groups of concepts and links to restructure the map. This process involves what Bloom (1956) identified as high levels of cognitive performance, namely evaluation and synthesis of knowledge. In this way, concept maps can serve as the indexing and navigational tools for complex domains of knowledge, as will be illustrated later with NASA materials on Mars (Briggs et al., 2004).
In our work with both teachers and students, small groups working cooperatively to construct concept maps have proven to be useful in many contexts. While concept maps on these public servers are only a sample of concept maps submitted by persons using CmapTools, and some do not meet our criteria of good concept maps, they nevertheless serve to illustrate diverse applications.
We have also found that the obstacles deriving from personal insecurities and fear of embarrassment are largely circumvented, since critical comments are directed at the concept map, not at the person(s) building the map. Experienced concept mappers agree with researchers that the most challenging and difficult aspect of constructing a concept map is constructing the propositions; that is, determining what linking phrases will clearly depict the relationship between concepts.

In this case, we are probably referring to using a relatively complete (not skeleton) map as a scaffold, expecting students to go deeper into the topic by creating several submaps that are linked to the starting point map. Here we also see a submap that might be created by a group of learners, and a sample of two resources that could be accessed via icons on the submap.
Thus, the learner or team of learners is very actively engaged in the meaning building process, an essential requirement for meaningful learning to occur. To begin, a€?expert skeletona€? concept maps have been prepared for some sections of the grade two book and the whole of the grade four book of the World of Science entitled The Expanding World of Science. This feedback should help us to rapidly refine concept maps, techniques and approaches for improving practice of the New Model for Education. Research (Bransford et al., 1999) has shown that factual information acquired in a context of meaningful learning is not only retained longer, but this information can be used much more successfully to solve new problems. Teachers should work collaboratively to build on some of the simpler concept maps dealing with education ideas and perhaps add resources to some of the more complex concept maps. There is nothing written in stone that says multiple choice tests must be used from grade school through university, and perhaps in time even national achievement exams will utilize concept mapping as a powerful evaluation tool. Thus, in curriculum planning, we need to construct a global a€?macro mapa€? showing the major ideas we plan to present in the whole course, or in a whole curriculum, and also more specific a€?micro mapsa€? to show the knowledge structure for a very specific segment of the instructional program. For these students, the subject matter of most disciplines, and especially science, mathematics, and history, is a cacophony of information to memorize, and they usually find this boring.
In fact, the biography of one Nobel Lauriat in biology (Barbara McClintock) was entitled, A Feeling for the Organism (Keller, 1983).
However, when we began to concept map the expert knowledge of a cardiologist who literally a€?wrote the booka€? on this technology, it was evident that there were concepts missing in the map and that the a€?tacit knowledgea€? of our expert was not fully expressed in his book or in our interviews.
In addition to submaps, a wide variety of digital resources can be accessed via the concept maps. Knowledge modeling and the creation of el-tech: A performance support system for electronic technicians. The results of the analysis of acid – base disturbances from our previous study [26] performed in the intensive-care unit in diabetics and non-diabetics suffering acute myocardial infarction are shown in Fig.
Moreover, it seems that rise in the serum lactate level between diabetics and non-diabetics with AMI was not accounted for the differences in oxygen delivery, since hemoglobin saturation was much the same in both groups. Some of the management guidelines may be defined here: It is important that patients with stroke complicated by DKA avoid dehydration since both DKA and stroke correlate with the pro-thrombotic state and dehydration potentates a tendency toward intravascular thromboembolism.
Propositions are statements about some object or event in the universe, either naturally occurring or constructed. Out of the necessity to find a better way to represent childrena€™s conceptual understanding emerged the idea of representing childrena€™s knowledge in the form of a concept map.
This acquisition is mediated in a very important way when concrete experiences or props are available; hence the importance of a€?hands-ona€? activity for science learning with young children, but this is also true with learners of any age and in any subject matter domain.
Typical objective tests seldom require more than rote learning (Bloom, 1956; Holden, 1992). Our brains have a remarkable capacity for acquiring and retaining visual images of people or photos.
While we can locate regions of the brain that are active in learning or recall of information using positron emission tomography (PET) scans, the specific mechanisms by which neurons store this information is not known. Nevertheless, we seen the organizing opportunities afforded by associating the various activities with an explicit knowledge structure as very beneficial.
The primary reason we have seasons in latitudes away from the equator is due to the tilt of the earth on its axis toward the sun in summer resulting in longer days and more direct radiation, thus greater heating. Learners struggling to create good concept maps are themselves engaged in a creative process, and this can be challenging, especially to learners who have spent most of their life learning by rote.
Some concepts may remain in the parking lot as the map is completed if the mapmaker sees no good connection for these with other concepts in the map.
When CmapTools is used in conjunction with a computer projector, two or more individuals can easily collaborate in building a concept map and see changes as they progress in their work. Concept mapping is an easy way to encourage very high levels of cognitive performance, when the process is done well.
In the early 1990s, Latin America, students using the IBM Net (before the Internet) were very successful in creating concept maps both with students in their classroom and with students in other countries (CaA±as et al., 2001).
When a concept map is saved to a CmapServer, a a€?web pagea€? version of the map is also stored, so a WWW browser is sufficient to browse through all the published concept maps. Having learners comment on each othera€™s concept maps, whether they are in the same classroom or in different schools, is an effective form of peer-review and collaboration.
So giving the student some of the concepts does not take away from the difficulty in the map construction, although it may somewhat limit the creativity of the student in selecting the concepts to include.
The CmapTools Network may serve as a clearinghouse for some of these efforts through its Public servers in Italy and other countries.
Even with the current state of technology and pedagogical understandings, it is possible for schools, states or countries to mount a New Model for Education.
This is a chicken-and-egg problem because concept maps cannot be required on national achievement tests if most students have not been given opportunities to learn to use this knowledge representation tool. Faculty working independently or collaboratively can redesign course syllabi or an entire curriculum. Nonaka and Takeuchi (1995) stress the importance of capturing and using the knowledge of corporate experta€™s tacit knowledge if a company wants to become a€?the knowledge creating companya€?.
Thus, the concept map not only allowed us to represent the experta€™s knowledge, but also to find gaps in the knowledge structure we were procuring through interviews. Paper presented at the Seventh World Conference on Artificial Intelligence in Education, Washington DC. Online concept maps: Enhancing collaborative learning by using technology with concept maps. Paper presented at the Symposium at the 11th Biennial Conference of the European Association for Research in Learning and Instruction (EARLI), Cyprus. A case study in the research paradigm of human-centered computing: Local expertise in weather forecasting. Why minimal guidance during iInstruction does not work: an analysis of the failure of constructivist, discovery, problem-based, experiential, and iInquiry-based teaching.
Therefore, it seems that DKA itself caused further tissue hypo-perfusion and contributed to serum lactate rise.
Since the use of osmotic and sometimes also other kinds of diuretics is inevitable in patients with stroke a careful hydration is recommended in order to avoid further thrombotic complications. Propositions contain two or more concepts connected using linking words or phrases to form a meaningful statement.
In fact, the worst forms of objective tests, or short-answers tests, require verbatim recall of statements and this may be impeded by meaningful learning where new knowledge is assimilated into existing frameworks, making it difficult to recall specific, verbatim definitions or descriptions.
For example, in one study (Shepard, 1967) presented 612 pictures of common scenes to subjects, and later asked which of two similar pictures shown was one of the 612 seen earlier? Other ideas for improving instruction to achieve understanding of the subject is available elsewhere (Mintzes et al., 1998).
In winter, the axis of the earth points away from the sun, thus resulting in shorter days and less intense radiation. Rote learning contributes very little at best to our knowledge structures, and therefore cannot underlie creative thinking or novel problem solving.
CmapTools also allows for collaboration between individuals in the same room or anywhere in the world, and the maps can be built synchronously or asynchronously, depending on the mapmakersa€™ schedules.
This is one reason concept mapping can also be a very powerful evaluation tool (Edmondson, 2000).
In our own classes and workshops, and in classes taught by our students and colleagues, small groups of students working collectively to construct concept maps can produce some remarkably good maps. Whenever a concept map is made with CmapTools and then saved, the maker is asked to provide a focus question, as well as key concepts for this concept map. It does provide the teacher with insight into which concepts the student(s) had trouble integrating into the concept map, indicating little or no understanding of these concepts. The a€?expert skeletona€? concept maps would serve as a starting point for students and teachers for each section illustrated in the book, and then students would use these Cmaps together with CmapTools to search the WWW for pertinent resources and ideas. We anticipate that an abundance of both anecdotal and empirical data will flow from these efforts in a few years. On the other hand, if state, regional, and national exams would begin to include concept maps as a segment of the exam, there would be a great incentive for teachers to teach students how to use this tool. For example, faculty working together to plan instruction in veterinary medicine at Cornell University constructed the concept map shown in Figure 15. Cardiovascular accidents have a marked place among the possible causes of diabetic ketoacidosis. Fluid resuscitation must be performed carefully, in small aliquots, and with constant monitoring of blood pressure, hematocrit and plasma sodium; novel minimal invasive procedures [39] should have advantages over central venous catheter since CVP itself was reported to be a risk factor for cerebrovascular thromboembolism [33]. This kind of problem was recognized years ago in Hoffmana€™s (1962) The Tyranny of Testing.
What is interfering with these 21 Harvard people is confusion with the common experience that when we are closer to a fire or lamp, the heat is more intense than when we are further away.
As people create and observe new or existing objects or events, the creative people will continue to create new concents and new knowledge. Figure 13 illustrates one of the a€?expert skeletona€? concept maps that could be used as the starting point for building a knowledge model, preferably students working in teams and sharing ideas. Based on the solid theoretical and related research findings now available, there is every reason to be optimistic that these innovative efforts will be successful. Cardiovascular morbidity influences the severity and duration of diabetic ketoacidosis and limits the first and most important step in its treatment- the fluid resuscitation. Excessive use of diuretics may precipitate pro-thrombotic state.Infused insulin is the principle therapeutic tool for fighting DKA in patients with cerebrovascular accidents. Figure 1 shows an example of a concept map that describes the structure of concept maps and illustrates the above characteristics.
Three days later, they were still 92% correct, and three months later they were correct 58% of the time. Thus, these people have failed to recognize that this same phenomenon is not operating to give seasons on Earth. Creating new methods of observing or recording events usually opens up new opportunities for new knowledge creation. Currently there are a number of projects in the USA and elsewhere that are doing research to see if better evaluation tools can be developed, including the use of concept maps. Boumedine (Ed.), Proceedings of IKS 2002 - the IASTED international conference on information and knowledge sharing (pp.
The resulting hyperosmolarity of body fluids precipitates a pro-thrombotic state, thus aggravating prognosis in patients with myocardial infarction.
Since fluid resuscitation must be restricted, DKA itself is expected to have more prolonged clinical course.
This and many other studies have shown that humans have a remarkable ability to recall images, although they soon forget many of the details in the images. For example, the creation of the concept mapping method for recording subjecta€™s understandings has led new opportunities to study the process of learning and new knowledge creation. The excess in-hospital mortality of diabetic patients results primarily from an increased incidence of congestive heart failure, severe coronary artery disease, decreased vasodilatory reserve of epicardial artery resistance, abnormal metabolism of myocardial substrate, diffuse nature of the atherosclerotic disease and hyper-coagulable state. This may be of importance, since DKA itself may be a precipitating factor for stroke (see later)Serum potassium must be carefully monitored in all cardiovascular patients with DKA (see earlier). Considering how often we look at pennies, it is interesting that the subjects asked to draw a penny in a study by Nickerson and Adams (1979) omitted more than half of the features or located them in the wrong place. This is commonly observed in many, many examples of a€?misconceptionsa€? in every field of study. Some features of the latest versions of CmapTools also facilitate the use of concept maps for assessment. Hyper or hypokalemia should be promptly corrected; thus said, insulin-induced intracellular shift of potassium must be taken in account when evaluating potassium levels or performing potassium substitution Bicarbonate therapy is not recommended except in extreme acidosis. We believe that integrating various kind of images into a conceptual framework using concept mapping software like CmapTools (described below) could enhance iconic memory, and we hope research on this will be done. The only solution to the problem of overcoming misconceptions is to help learners learn meaningfully, and using concept maps can be very helpful. For example, the a€?Compare concept mapsa€? tool allows the comparison of an a€?experta€? concept map for a topic with maps constructed by students, and all similar or different concepts and propositions are shown in color.
Not only does stroke precipitate DKA, but the vice-versa is also true [20]: diabetic ketoacidosis itself was reported as a risk factor for the occurrence of stroke in children and youth.
The pH was normalized at a price of the increased respiratory effort to lower the PaCO2 which may lead to respiratory muscle fatigue.Additional risk factors for development of hyperosmolarity include the presence of congestive heart failure, impaired thirst, limited access to water (especially in patients with dementia or who are bed bound), older age, and poor kidney function. The similar mechanisms are operative in developing cerebrovascular injury in diabetics [18].
The risk of acute ischemic or hemorrhagic stroke during the acute DKA episode is perhaps under-appreciated. Table 1 depicts the significant correlations of pH values and certain clinical and biochemical parameters in diabetics suffering AMI. Systemic inflammation is present in DKA, with resultant vascular endothelial perturbation that may result in coagulopathy and increased hemorrhagic risk. Diabetic acidosis itself may be the precipitating event for the occurrence of serious arrhythmia, pulmonary edema or even acute myocardial infraction [22].
Hyperglycemia and acidosis may contribute to oxidative injury [25], as well as ischemic injury [34].
Thrombotic risk during DKA is also elevated by abnormalities in coagulation factors, platelet activation, blood volume and flow, and vascular reactivity. Recent data demonstrate that DKA is associated with reduced cerebral blood flow and with brain cell swelling [23]. They cause negative inotropy, bradycardia, reduced cardiac output, peripheral vasodilatation and severe shock. Sometimes, a bio-marker elevation is also noted, without further evidence of a true myocardial infarction [42]. On the other hand iatrogenic or spontaneously occurring hyperkalemia may lead to ventricular tachycardia or fibrillation, intra-ventricular conduction defects, sine wave, slow ventricular escape rhythm or ventricular stand. Although a small percentage of children have clinically apparent cerebral injury at presentation of DKA prior to treatment, neurological decline during DKA treatment is more common [16]. Hyperkalemia can also induce a current of injury called ‘dialyzable current of injury’, which can cause ST-segment elevation and thus be mistaken for acute infarction. During initial DKA treatment with insulin and intravenous saline, key aspects of the cerebral metabolic state worsen. After initiation of DKA therapy, abnormalities in Protein C, Protein S, plasma homo-cysteine, and von Willebrand Factor (vWF) were demonstrated [11, 9].
Pseudo-infarction presents a unique danger for the clinician treating these critically ill patients. While protein C levels normalize with treatment, free protein S, the active anticoagulant of protein S, is reduced and does not return to baseline with treatment.
While the mechanism of these and other temporary electrocardiographic changes in diabetic ketoacidosis remains unclear, appreciation of their transient nature is essential if misdiagnosis of myocardial infarction and possible inappropriate delay in intravenous fluid administration are to be avoided [21].
Arterial ischemic stroke [47], cerebral venous thrombosis [29], and hemorrhagic stroke [36] were noted in children following DKA. However a true myocardial necrosis was also reported with the DKA as the precipitating factor [50], which further complicates the management and the outcome of these patients.
DKA-associated cerebral edema may also predispose to ischemic injury and hemorrhage, though cases of stroke without concomitant cerebral edema have been identified [49].
A pulmonary edema in the absence of left ventricular failure has also been reported in DKA and may be a variant of adult respiratory distress syndrome (ARDS). As stroke itself may cause cerebral edema, it becomes difficult to ascertain whether cerebral edema in DKA is the cause or an effect of acute cerebral infarction. A sub-arachnoid or intra-ventricular hemorrhage may occur without cerebral edema as was demonstrated using on CT scanning.
Clinically, a transcranial Doppler ultrasound in children with DKA demonstrated significant vascular dysregulation with vasodilation, decreased cerebral blood flow velocity, and loss of normal cerebral blood flow regulation that only normalized after treatment. Since volume repletion must be done cautiously and gradually, its therapeutic reach in diabetic ketoacidosis is limited. Another group of researchers found normal to increased cerebral blood flow with impaired cerebral auto-regulation during episodes of DKA not associated with overt CE in 6 children [20]. Intravenous insulin remains the keystone in treatment of diabetics with AMI, yet their recovery from ketoacidosis may be prolonged. Treatment with bumetanide, [27] an inhibitor of Na-K-2Cl Co-transport, resulted in improvements in metabolic measures during untreated DKA and amelioration of the declines in metabolic measures during initial DKA treatment.
Indeed, an endothelial injury, platelet activation, relative hypo-fibrinolysis, and activation of the coagulation system [20] even in the absence of clinical signs of thrombosis were all demonstrated in patients with DKA. However, the up-regulation was not to a degree expected for the increase in coagulation activity (thrombin-antithrombin III complex and prothrombin fragment 1 + 2 levels) at DKA presentation. In summary, cerebrovascular accidents represent a significant and well-known precipitating factor for DKA. It seems that the prevalence of DKA in patients with stroke may be underestimated and its importance under-appreciated in many cases. Unfortunately, like in acute myocardial infarction, the volume replenishment capacity in patients with stroke is often limited. Magnesium level should be monitored, especially in patients who receive diuretics and low levels should be corrected in order to avoid this and other complications of hypomagnesaemia.
Arterial ischemic stroke, cerebral venous thrombosis and hemorrhagic stroke were noted following DKA episodes. Heart failure following infarction reduces patients’ capacity for volume resuscitation, so clinical features of hyperglycemic hyperosmolar state and diabetic ketoacidosis may overlap and are observed simultaneously.
Treatment with bumetanide, an inhibitor of Na-K-2Cl co-transport, resulted in improvements in metabolic measures during untreated DKA and prevented cerebral metabolic aggravation during initial DKA treatment.3. Additional risk factors for development of hyperosmolarity include the presence of congestive heart failure, impaired thirst, limited access to water, older age, and poor kidney function. Diabetic ketoacidosis and renal failure Renal failure occurs with increased frequency in patients with diabetes. Fortunately, the coincidence of type 1 diabetes with DKA and acute renal failure is uncommon. Another consequence of tissue hypoperfusion resulting both from impaired myocardial output and increased osmolality as well as counter-regulatory hormone metabolic effects is increased lactate production.
It has been reported that DKA in patients with acute renal failure may be sometimes associated with respiratory distress syndrome [17]. Diabetic acidosis itself may be the precipitating event for the occurrence of a true myocardial necrosis.
Diabetic ketoacidosis and acute renal failure Although acute renal failure (ARF) rarely develops in patients with diabetic ketoacidosis (DKA), these serious complications can be life threatening in critically ill patients [43].
Also, the ECG changes in hyperkalemia in DKA can mimic acute anteroseptal myocardial infarction.
Moreover, a bio-marker elevation was also noted, without further evidence of a true myocardial infarction.
ARF pre-renal failure may occur as a result of the severe fluid depletion associated with diabetic ketoacidosis; underlying diabetic nephropathy as well as hypotension, sepsis, renal artery occlusion, serious urinary infections complicated by papillary necrosis and exposure to nephrotoxic agents. Knowing that “silent” myocardial infarction occurs with higher incidence among diabetics, the differential diagnosis between myocardial necrosis and hypokalemic disturbances may be difficult. Of the latter, a certain antibiotics and radio-contrast agents, but also angiotensin converting enzyme inhibitors were mentioned. The long-lasting ketoacidosis in combination with infused insulin can lead to severe hypophosphatemia. Patients with uncontrolled diabetes may already be predisposed to hypophosphatemia due to osmotic dieresis and often decreased muscle mass; however, the majority of the imbalance results from phosphate shift from extracellular to intracellular space[30]. In the presence of metabolic acidosis, proximal tubular reabsorption of phosphate is inhibited and their urinary excretion is initially increased, thereby critically reducing the overall level of the extracellular phosphate [10]. Diabetic ketoacidosis and cerebrovascular accidents Although cerebrovascular accidents represent a significant and well-known precipitating factor for DKA, the literature data on precise mechanisms, distinctive features or management guidelines for patients are quite few or missing.
Acidosis cannot be compensated by renal production of ammonia, because later in the course of diabetic ketoacidosis, with a reduction in the total amount of phosphate in the body, a reduction in urinary excretion of phosphate ensues. The prevalence of stroke as the precipitating factor for DKA was 0% in some studies [40] to as much as 7% in others [24]. Prolonged metabolic acidosis accompanied by hypophosphatemia may be the cause of transient rhabdomyolysis. 80%) were in the age 18-65 years, with only 18% younger than 18; even 24% of all patients with DKA were in the age 45-65 years [32] Based on these data, it seems that the prevalence of DKA in patients with stroke may be underestimated and its importance under-appreciated in many cases.
In addition, prolonged hypophosphataemia can lead to cardiomyopathy due to decreased concentration of intracellular adenosine - triphosphate and 2.3diphosphoglycerate (DPG). Cerebrovascular accidents lead to increased release of counter-regulatory hormones (catecholamines, cortisol) which lead to hyperglycemia. Hyperglycemia develops as a result of three processes: increased gluconeogenesis, accelerated glycogenolysis, and impaired glucose utilization by peripheral tissues. It is, therefore important to detect changes in serum phosphate levels of order in early to prevent these complications. Also these hormones increase the release of free fatty acids from peripheral tissues and their utilization as the energy source in hepatic and muscle mitochondria (beta-oxidation) with the increased ketone production as the direct consequence. Acute hypophosphatemia may be associated with respiratory problems, confusion, irritability, seizures, ataxia or coma, metabolic acidosis due to reduced phosphate reabsorption.
However, even the severe symptoms may be hardly recognizable for they can mimic those of the underlying disease – e.g. One can assume that an interference of symptoms of the two conditions during the clinical examination may be confusing and their interpretation difficult particularly in elder and less communicative patients. Hipophosphatemia may be the cause of rhabdomyolysis, which (though not often) can lead to occurrence of cardiomyopathy and acute renal failure.
Even after initiation of phosphate replacement, serum phosphate levels are often difficult to normalize, and a severe metabolic acidosis can last despite insulin-induced normalization of blood glucose. However, after initial-phase phosphate replacement, the re-institution of acid-base balance phosphate re-shifts from intra- to extracellular space; this can lead to the hyperphosphataemia later in the course of treatment [13]. With the occurrence of acute renal failure, indications for haemodialysis include oliguria, persistent metabolic acidosis resistant to standard therapy, fluid overload and hypertension. Early initiation of haemodialysis is not only effective against the direct consequences of acute renal failure - uremia and hypervolemia – but also contribute to rapid correction of metabolic acidosis and hypophosphatemia [28].
Indeed, the existing hypophosphataemia is easily corrected once a normal acid-base balance is established by haemodialysis. Prompt institution of dialysis is important as the diabetic patient may tolerate uraemia less well. Insulin requirements may be increased due to insulin resistance, or decreased due to impaired clearance of circulating insulin [38, 56].
Patients with cardiac dysfunction or autonomic neuropathy tend to develop hypotension during treatment.
Also, anticoagulation with heparin may increase the risk of hemorrhage from proliferative retinopathy, therefore prostacyclin may be a safer alternative [52]. Also, haemodialysis allows greater fluid removal and remove restrictions for administration of drugs and nutrition [56]. Diabetic ketoacidosis and chronic renal failure Despite the strong prevalence of compromised immune status, constant state of protein malnutrition, frequent vascular accessing with a predisposition to significant infections, increased incidence of cardiovascular diseases, the occurrence of DKA in patients with chronic renal failure is quite rare. Kidneys play a major role in insulin breakdown [38]; advanced chronic renal failure is associated with both insulin resistance and decreased insulin degradation. Therefore, many patients see an improvement in glycemic control when they progress to haemodialysis. Furthermore, in hyperglycemic dialysis-dependent patients volume contraction due to osmotic diuresis is not encountered. Since glycosuria and osmotic diuresis account for most of the fluid and electrolyte losses seen in DKA, anuric patients may be somewhat protected from dehydration.
However they may still be prone to development of hyperkalemia and metabolic acidosis [37]. In persistent and long-lasting DKA, a substantial volume loss can still occur due to a prolonged decrease in oral intake or increased insensible water losses related to tachypnea and fever.
Changes in dietary intake and exercise (ie, reduced intake due to anorexia prior to starting dialysis) can also affect the response to administered insulin).
In patients treated with peritoneal dialysis, glucose contained in peritoneal dialysate will tend to increase the need for hypoglycemic therapy. Therefore, the treatment of oliguric patient certainly differs from the wide accepted DKA treatment guidelines.
First of all, end-stage-renal-disease patients with DKA may be less likely volume depleted; in most cases the extracellular volume is expanded from its baseline secondary to hyperglycemia. In oliguric patient, fluid hydration in amounts usually administered in the DKA treatment may precipitate severe pulmonary edema.
Therefore, the need for fluid resuscitation in these patients must be justified clinically or by laboratory testing and potential volume resuscitation should be performed carefully, using central venous access for continuous monitoring. Insulin is normally metabolized by kidneys and in chronic renal failure insulin degradation is much slower. Hyperinsulinemia resulting from aggressive glucose – lowering therapies may easily lead to severe and prolonged hypoglycemia. One cannot readily predict insulin requirements in this setting and careful individualized therapy is essential.
As already emphasized, kidneys in end-stage renal disease are not able to contribute to the overall acid-base balance. In addition, pulmonary dysfunction related to volume overload and sometimes underlying pulmonary infections can impair respiratory compensation to metabolic acidosis. Bicarbonate administration is rarely of value in DKA [55] and the associated volume, sodium and osmotic overload may be particularly problematic for anuric patients. In this situation, significant metabolic acidosis will only be correctable by haemodialysis [53].
Total body concentration of potassium is unchanged, and patients with DKA and end stage renal failure frequently have a high serum potassium level. Lack of insulin causes translocation of intracellular potassium to the extracellular compartment. Hyperglycemia causes hypertonicity of extracellular fluids, which also leads to shift of potassium from the cells to the extracellular compartment. Even when testing reveals hypokalemia, total body potassium stores may be high, and these patients are unable to excrete a potassium load. Consequently, hypokalemia must be documented and acidosis corrected before potassium supplementation is initiated. All dialysis patients presenting with significant symptoms should undergo immediate cardiac monitoring.
If there is clinical suspicion or electrocardiographic evidence of hyperkalemia, they should receive immediate potassium lowering therapies, including emergent haemodialysis.
In a study performed in USA in 2001 [1] the occurrence of diabetic ketoacidosis after renal transplantation was followed. Diabetic ketoacidosis was independently associated with increased mortality.In summary, acute renal failure rarely develops in patients with diabetic ketoacidosis, but it can be life-threatening. Insulin requirements may be increased due to insulin resistance, or decreased due to impaired clearance of circulating insulin.
In the presence of metabolic acidosis, proximal tubular reabsorption of phosphate is inhibited, and the overall level of the extracellular phosphate is further reduced. Indications for haemodialysis in patients with acute renal failure and DKA include oliguria, persistent metabolic acidosis resistant to standard therapy, fluid overload and hypertension. Early initiation of haemodialysis is not only effective against uremia and hypervolemia but also contribute to rapid correction of metabolic acidosis and hypophosphatemia. Chronic renal failure is associated both with insulin resistance and decreased insulin degradation. In oliguric patients, fluid hydration in amounts usually administered in DKA treatment may precipitate severe pulmonary edema. Pulmonary dysfunction due to frequent pulmonary infections can impair ventilatory compensation to metabolic acidosis. In this situation, significant metabolic acidosis will only be correctable by haemodialysis. Most DKA patients on both peritoneal and haemodialysis are hyperkalemic and the potassium replacement in DKA is usually not necessary. ConclusionDiabetic ketoacidosis is serious metabolic complication in diabetic patients with acute myocardial infarction, stroke and renal insufficiency. Conversely, severe diabetic ketoacidosis is an important risk factor for acute myocardial infarction, stroke and acute renal failure.
In all of the three conditions a fluid resuscitation in quantities commonly used in the treatment of DKA can not be performed.
In chronic renal insufficiency, on the contrary, intensive insulin therapy usual for the treatment of ketoacidosis may carry a risk of hyperinsulinemia and prolonged hypoglycemia.
Electrolyte imbalance, especially potassium deficiency or excess can have serious consequences, especially in patients with myocardial infarction, and special care should be given to electrolyte monitoring.Finally, we believe that more attention should be paid to the possible acid-base disorders in diabetic patients suffering cerebrovascular insults. Clinical assesment in these cases is not sufficient because the significant overlapping of the signs and symptoms, therefore DKA symptoms may be attributed to cerebrovascular pathology.
The conclusions based on blood glucose levels would not be appropriate, since glycemia tends to be high in distressed patients.

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