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Protein kinase phosphorylates enzymes/proteins and either activate or inactivate them buy indapamide 2.5 mg amex. Urinary metabolites of epinephrine and nor-epinephrine are estimated for the conformation of diagnosis cheap indapamide 2.5mg on-line. Case histories Case I Then years old with bulging eye balls went for a medical checkup order 2.5mg indapamide fast delivery. Lab Investigations Result Reference Range SerumT3 260μg/100ml 70-180 μg/100ml SerumT4 18 purchase indapamide 2.5 mg otc. It could be due to loss of feed back sensitivity of pituitary to Thyroid hormones order 2.5mg indapamide free shipping. Thus failure of feed- back inhibition of anterior pituitary by thyroid hormone is the pathological basis of the patient’s condition. Following a normal overnight fast and a cup of black coffee, a diabetic woman feels slightly nauseous and decides to skip breakfast. As per schedule, she decided to lake her insulin shot what is the result of her action? Insulin should be given only when blood glucose level can be maintained by dietary or stored glycogen. When blood glucose is low, if insulin is given, severe hypoglycemia might result, further it can lead to insulin shock. In the present case, patient has not taken breakfast, insulin shot might result in hypoglycemia. If insulin shock occurs, then administration of intravenous glucose will save the patient. Each deoxyribonucleotide is composed of deoxyribonucleoside & inorganic phosphate group. The linkage in pyrimidine nucleotide is between 1 of sugar ribose and 1 of pyrimidine bases. The sugar – phosphate linkages form the backbone of the polymer to which the variable bases are attached. The sequence of the polymer is written in the 5’ to 3’ direction with abbreviations to different bases e. That means, the 5’ ---- 3’ of one strand is in opposite direction to the other strand. The bases of one strand pairs with the bases of the other strand of the same plane such that adenine always pairs with thymine with two bonds. The negatively charged phosphate group and the sugar units expose themselves to the outside of the chain. The two antiparallel polynucleotide chains are not identical, but they are complimentary. The purine, pyrimidine bases are on the inside of the helix, the phosphate and deoxyribose groups are on the outside. A to T is bonded by two hydrogen bonds (A= T), Guanine is bonded to cytosine by three hydrogen bonds. The double helix is stabilized by interaction between stacked bases of the same strand. Ribonucleotide differs from deoxyribonucleotide in that ribonucleotide contains “O” in the carbon 2’ sugar ribose. Site Nucleus, mitochondria Nucleus, ribosome, cytosol, but never in cytosol Nucleolus, mitochondria 4. Ribosomes are ribonucleotide-protein particles, serve as work benches for protein synthesis. According to their sedimentation rates, the subunits are referred as 30S, & 50S, together they form 70S unit. Here in the intestine, the nucleotide is also hydrolyzed to nucleoside and phosphoric acid. Finally adenine and guanine are converted to uric acid in our body which is excreted through urine. Since uric acid has a precipitation character, excess uric acid in kidney causes kidney stone and in joints causes gout. It is the way in which the genetic information can pass from parental cell to daughter cell. In prokaryotic cell the primer length is about 10 - ribonucleotides, but in Eukaryotic cell it is about ’ 30. There are blisters on the skin, hyperpigmentation and finally atrophy of the effected skin. But in eukaryotic cells termination may occur by transcription factors themselves.

Surgery may be considered for patients with symptomatic Crohn’s disease localized to a short segment of bowel cheap indapamide 1.5 mg line. Data are lacking demonstrating the effectiveness of sulfasalazine or of olsalazine for the maintenance of medically induced remission in patients with Crohn’s disease and are these agents not recommended for long-term treatment order 1.5mg indapamide with amex. Prophylactic treatment is recommended after small intestinal resection in patients with risk factors for recurrence purchase indapamide 2.5 mg. Risk factors for postoperative Crohn’s disease recurrence should be taken into account when deciding on treatment buy indapamide 2.5 mg online. A resection of a segment of diseased intestine is the most common surgery for a Crohn’s disease order indapamide 1.5mg on line. Crohn’s disease patients who develop an abdominal abscess should undergo a surgical resection. However, some may respond to medical therapy after radiologically guided drainage. Objective evaluation by endoscopic or cross-sec- Population-based studies from Denmark and Minnesota tional imaging should be undertaken periodically to avoid errors of suggest that between 43 and 56% of Crohn’s disease patients under- or overtreatment (Summary Statement). In population-based cohorts, the frequency of perianal fstulas is Up to 80% of patients with Crohn’s disease require hospitalization between 10 and 26%, and the cumulative risk was 26% at 20 years at some point during their clinical course, but the annual hospitali- afer diagnosis in one cohort (9,14,15). Perianal disease at diagno- zation rate decreases in later years afer diagnosis (Summary State- sis may indicate a more severe clinical course of Crohn’s disease. Symptoms of Crohn’s disease occur in most cases as a chronic, inter- An older Copenhagen County study suggested that 83% of mittent course; only a minority of patients will have continuously patients were hospitalized within 1 year of diagnosis, and the active symptomatic disease or prolonged symptomatic remission annual rate of hospitalization thereafer was about 20% (18). The annual rate of hospitalization was highest modeled the lifetime course of Crohn’s disease in various disease in the frst year afer diagnosis (15). In the 1962–1987 Copenhagen County cohort, within the frst year afer diagnosis, In a systematic review of 30 publications examining major the proportions of patients with high activity, low activity, and clini- abdominal surgical risk in Crohn’s disease, the cumulative cal remission were 80%, 15%, and 5%, respectively (17). Among Crohn’s disease patients who undergo major abdominal surgery, the 5-year cumulative risk of clinical recurrence is 40% to Routine laboratory investigation 50% (22,23). Initial laboratory investigation should include evaluation for Risk factors for recurrent Crohn’s disease postoperatively include infammation, anemia, dehydration, and malnutrition (Summary cigarette smoking, shorter duration of disease before operation, Statement). In patients who have symptoms of active Crohn’s disease, stool testing Overall mortality in Crohn’s disease is slightly increased, with a should be performed to include fecal pathogens, Clostridium difcile standardized mortality ratio of 1. Recommendations A 2007 meta-analysis of 13 studies of Crohn’s disease mortality 1. Fecal calprotectin is a helpful test that should be consid- yielded a pooled standardized mortality ratio of 1. Anemia and an elevated corticosteroids and increased mortality in Crohn’s disease (26,27). It has a short Patients with colonic involvement are at increased risk of colorectal half-life of 19hours. Erythrocyte colorectal cancer, and severity of ongoing colonic infammation sedimentation rate is also a nonspecifc measure of infammation (Summary Statement). Similar to ulcerative colitis, risk factors for syndrome or healthy controls (36). Fecal calprotectin is a calcium binding protein that is derived from neutrophils and plays a role in The relative risk of small bowel adenocarcinoma in patients the regulation of infammation. Fecal lactoferrin is an iron binding with Crohn’s disease is markedly elevated (at least 18-fold), protein found in secondary granules of neutrophils. Fecal markers may also be useful in monitor- ing disease activity and response to treatment (see later section). Laboratory testing is complementary in expressions in Crohn’s disease but testing remains a research tool at assessing disease severity and complications of disease. Direct evaluation of the identifed through large-scale genome-wide association studies ileum will complement radiographic fndings in the diagnosis of (43–45). Examples of single-nucleotide polymorphisms larity, edema, ulcerations, friability, and stenosis (53,55). Disease distribution of endoscopic and histologic fndings is innate immunity and regulation of the epithelial barrier (47). These variants are also associated with early disease have shown excellent intra- and inter-rater reliability (58) (see later onset (49). These studies have been carried out predominately that would assist in disease diagnosis. Despite these fndings there does not appear to be any on antibodies to microbial antigens and autoantibodies (Supple- clinical signifcance related to these mild changes (62). Histologic changes may include granulomatous infam- mation, focal cryptitis of the duodenum, and focally enhanced Endoscopy gastritis (60). Ileocolonoscopy with biopsies should be performed in the assessment of patients with suspected Crohn’s disease (Summary Statement). Video capsule endoscopy is a useful adjunct in the diagnosis of patients with small bowel Crohn’s disease in patients in whom there Disease distribution and severity should be documented at the time is a high index of suspicion of disease (Summary Statement). Biopsies of uninvolved mucosa are recommended to identify extent of histologic disease (Summary Statement).

Responding web participants reported similar symptoms to those participating in person cheap indapamide 1.5 mg amex. The facilitated discussion provided a detailed view into how these symptoms manifest purchase indapamide 2.5mg overnight delivery. Throughout the discussion indapamide 2.5mg without prescription, participants commented on the unpredictability of their Parkinson’s disease symptoms purchase 1.5 mg indapamide amex, and many shared their experiences on how symptoms have progressed indapamide 1.5mg mastercard. Motor Symptoms The most frequently identified symptoms by in-person and web participants were motor symptoms. Meeting participants described the manifestation of motor symptoms using a wide range of terms such as bradykinesia, dyskinesia, and dystonia. One participant expressed his bradykinesia as, “not just a physical change in movement, velocity, but a pervasive slowing of thought patterns, like a freezing of synapses. I was carrying one end of a cabinet to install and could not stop [moving forward]. One caregiver shared that over a period of 3 years, her mother’s Parkinson’s disease progressed from stiffness to being fully wheelchair bound. One participant echoed this comment sharing, “Since my diagnosis nine years ago, difficulty moving has increased exponentially and now includes problems walking, eating, showering, turning over in and getting out of bed. One participant shared that the fear of falling “is always in the back of my mind. Participants’ also identified additional triggers 6 that worsened their motor symptoms including: lack of sleep, anxiety, large crowds, stress, temperature change, and the feeling of being rushed to complete a task. Cognitive Impairment Several participants highlighted the cognitive effects of Parkinson’s disease on their day to day activities. For some participants, cognitive impairment was manifested as being unable to remember words, particular periods of time and people. Participants shared specific instances: • “If you asked me, I wouldn’t [be able to] tell you what I had for breakfast. A wide range of sleep disturbances were reported, including difficulties falling asleep and staying asleep. Participants also mentioned that sleep disturbances sometimes lead to fatigue symptoms which may persist into the next day. One woman stated, “Using the restroom is difficult…because my stomach muscles are often too cramped. Some participants expressed the need for constant monitoring of their diet due to constipation. One participant shared, “I have to really watch meat…it will take me several days to digest and cause constipation. One participant commented that her anxiety occurred whenever she needed to “complete a particular task. Overall impact of Parkinson’s disease on daily life Throughout the meeting, participants described the physical and social impact that living with Parkinson’s disease has had on their lives. Many also highlighted the emotional burden of living with Parkinson’s disease, sharing that their condition felt “frustrating” and “incredibly scary. Several participants highlighted the effect of this reliance upon how they care for and are perceived by their family. One participant noted that family members sometimes become frustrated with his lack of ability to complete a task. He shared his family’s sentiments: “Better not give him that assignment if you want it done before the end of the day. The following examples illustrate the experiences shared in the discussion of this impact: o “I’m supposed to be the caregiver of my children…they’re only teenagers, and they’re beginning to help. Participants shared that their symptoms, particularly motor symptoms, impaired balance, and cognitive impairment, had significant impacts on their ability to perform at their job. One participant shared an experience of quitting a position due to impaired balance, stating, “the responsibility [of the position]…it was just haunting me and causing me to fall down. Many participants commented that the lack of energy, anxiety, and motor symptoms led to social isolation. One participant shared that she had increased anxiety when making social plans, saying, “, I often cancel at the last minute because I get so anxious going out. Some participants shared instances of being characterized as lazy or “looking a little slow. Topic 2: Patient Perspectives on Treatments for Parkinson’s disease The second discussion topic focused on patients’ experiences with therapies used to address their Parkinson’s disease symptoms. Five panelists, including four men and one woman, provided comments to start the dialogue. Two men discussed the hardships of pursuing treatment due to lack of timely diagnosis, one man shared detailed experiences with deep-brain stimulation, another man stressed the importance of seeking healthcare professionals which specialize in Parkinson’s disease management and one woman highlighted the importance of emerging research in stem cells and regenerative medicine. Panelists shared their experiences with complex regimens which included a variety of prescription treatments, alternative therapies, and lifestyle changes. In the large-group facilitated discussion that followed, experiences voiced by participants reflected those shared by panelists. Participants identified the importance of a personalized treatment regimen incorporating experiences of supplement and vitamin use, prescription drugs and lifestyle modifications in efforts to manage symptoms.

When taken in sufficient dosage cheap 2.5mg indapamide visa, any of these substances will produce illusions (incorrect perception of objects) and hallucinations (a sensory perception without objective stimulus purchase 2.5mg indapamide overnight delivery, such as seeing indapamide 1.5 mg with visa, hearing discount 1.5 mg indapamide fast delivery, feeling generic indapamide 1.5mg with mastercard, tasting, or smelling something that does not exist. In high doses they also cause physical symptoms such as dilated pupils, sweating, increased heart rate, blurred vision, tremors and in-coordination. Persons under the influence of hallucinogens often sit or recline quietly in a dream or trance-like state. Users put drops of the liquid into beverages, on sugar cubes, crackers, or a small paper wad or cloth. When buying drugs on the street, it is impossible to know the actual content of the product. The customer is unaware the hallucinogen is in the drug, and its effects contribute to a “bad trip”. However, skilled help may be required if the user, often inexperienced, suffers a loss of control and is overwhelmed with anxiety, terrifying sights and sounds, delusions of persecution, extreme depression and/or the belief that he is going out of his mind. Limiting external stimuli, such as having the patient lay down to relax in a quiet darkened area, can be helpful. If radio consultation is sought and diazepam is recommended, be certain of other drugs the patient may have taken to avoid dangerous, even fatal, interactions. The drug can act as a stimulant; the user may be very animated and appear almost hysterical. Marijuana smokers may be identified by their possession of cigarettes or other smoking paraphernalia. The cigarettes, called sticks, reefers, or joints, are hand rolled in off-white cigarette papers. Smaller than a regular tobacco cigarette, with the paper twisted or tucked in on both ends, the marijuana cigarette often contains seeds and stems. Another clue to the presence of marijuana is the way it is smoked - the smoke is inhaled deeply and held in the lungs as long as possible. Marijuana use affects reflexes, distorts sensory perceptions and impairs the user’s abilities. Each crew member must understand the ship’s policies regarding its purchase and use during port calls. The user is unaware of these other drugs at the time of purchase, and there is no way to determine what the drug combination actually is. As a fast-acting central nervous system stimulant, it results in a rapid “rush” and binge use is common. The active ingredients are easily vaporized and inhaled, resulting in a rapid onset of action with an immediate “high”. Cocaine use can result in a range of symptoms – paranoia, aggressive behavior, violence, anxiety, and depression. Many researchers believe the drug changes the brain’s chemistry, and results in drug craving. Cocaine disrupts the individual user’s life, and also is a major public health problem. The vapors they produce can be extremely dangerous when inhaled; many cause permanent brain damage. Examples are gasoline, glue, lighter fluids (butane), paint, wet markers, propellants in aerosol spray cans, and nitrous oxide. Some chemicals, 4-14 such as the nitrite inhalants (“snappers” and “poppers”), are produced as intoxicating drugs. Inhalants can be abused by “sniffing” (inhaling through the nose directly over an open container), or “huffing” (pouring or spraying material on a cloth that is held over the mouth and inhaling through the mouth. Persons who regularly abuse inhalants risk permanent and severe brain damage and even sudden death. The vapors from these volatile chemicals can react with the fatty tissues in the brain and literally dissolve them. Acute and chronic damage may also occur to the heart, kidneys, liver, peripheral nervous system, bone marrow, and other organs. Sudden death can occur from respiratory arrest or irregular heart rhythms that are often difficult to treat even if medical care is quickly available. The acute signs and symptoms of inhalant abuse resemble a combination of alcohol and marijuana intoxication. Physical symptoms of withdrawal from inhalants include hallucinations, nausea, excessive sweating, hand tremors, muscle cramps, headaches, chills and delirium tremens. Thirty to forty days of detoxification is often required, and relapse is frequent. Treatment During the acute episode, if physically stable but emotionally distraught, the patient can be treated by “talking-down,” recognizing the possibility of hostile outbursts. As with other substance abuse problems, a drug/alcohol assessment screening by a qualified screener as soon as the ship arrives in homeport may be indicated. Substances of abuse have both short- and long- term effects on the health of the individual crew member. Serious medical consequences, including death, can result from unintentional overdoses, especially if more than one drug is taken at a time.

The Medical Services generic 1.5mg indapamide otc, like any other airline department must function efficiently buy indapamide 1.5mg overnight delivery, providing a cost effective service purchase indapamide 2.5 mg mastercard. The Medical Services also need to have a reporting line such that medical issues that may affect either passengers or employees are brought to the attention of the most senior airline staff without delay and these are recognised and evaluated quickly so prompt action can be taken generic 2.5 mg indapamide overnight delivery. Some airlines are prepared to subsidise their medical departments order indapamide 2.5 mg with amex, allowing them to provide the required services at a loss, but many insist on strict budgetary controls. Some Medical Services operate very effectively on a system of costing and charging other areas of their company for their services. This might seem unduly bureaucratic, but it can show most clearly to other departments within the organisation the value of the Medical Services and the costs relative to external providers. Within these domains it may provide any or all of the following functions: - Passenger health - Occupational health - Aircrew health and medical certification - Alcohol and other drugs programs - Health and wellbeing promotion - Health strategy and risk management - Primary care service 1 Medical Manual 1. Advisory service for passenger health standards, policy and procedures, and strategic matters In this area, the issue of passengers with reduced mobility requires particular attention as many States have specific regulations on this matter. In addition to setting standards, policy and procedures, the Medical Services can address passengers’ real or perceived concerns about their flight directly, or indirectly through travel agents or the airlines’ sales agents. The use of pamphlets at points of sales, and in ticket wallets, airline internet sites and in-flight magazines are all useful vehicles to provide important health information and advice for passengers and their medical advisors. This function insures that the traveling ill passenger meet established standards and policy, and will minimize the chance of deterioration in-flight. Investigation and review of data for inflight medical events including medical diversions, resuscitations and deaths with advice on remedial actions or system improvements. Inflight medical events and provision of inflight medical care received frequent media attention. The Medical Services can provide a balanced scientifically based view, keeping abreast of medical research, using proven medical data which is made widely available to all. Advisory service for public health outbreaks of airline significance and medical business issues. In this context, it is strongly recommended that the airline maintain good and regular contact with the local and national public health authorities and align each other’s emergency response plan for public health emergencies. Among other things, this relationship is very profitable for both parties to deal with contact tracing when required. The Occupational Medicine service provides specialist medical advice that augments and integrates an Occupational Rehabilitation Service. Specialist advice on standards, policies and procedures involving fitness for duty In order to protect its employees and comply with local laws, the company needs policies and processes for medical assessments such as pre-employment/pre-placement assessments, functional capacity assessments and confined space assessments. The importance of pre-employment/pre-placement assessments cannot be over emphasised. A proper pre-employment/pre-placement medical assessment may avoid many problems including serious medico-legal issues later on. The examining health professional must be aware of the physical and mental components of specific jobs and the possible hazards of the environment in which the applicant will be required to work. The assessment should focus on the safety of the applicant and others, and on the airline’s duty of care. Any relevant past medical history needs to be carefully checked and assessed for its potential impact on future employment in the airline. The pre-employment/pre-placement assessment provides the base information for the employee’s occupational health record. Failure to have such at the pre-employment stage can result later in significant and serious implications for the airline if the employee alleges an illness/injury or condition is the direct result of their employment. A declaration such as follows, gives a reasonable degree of safety to both parties: 3 Medical Manual “I hereby declare that the answers to the above questions are correct and that I have not withheld any relevant information or made any misleading statements in relation to any medical condition experienced by me either in the past or at present. In order to ensure safety and for various operational reasons, we require you to complete this form in good faith and to make a full and frank disclosure of your medical history. Your employment, and continued employment, by the Company is conditional on your having provided us with complete details of your medical history and existing medical conditions. In the event that you fail to disclose any medical condition, such failure will entitle the company, at its discretion, to withdraw your offer of employment or to terminate your contract of employment, whichever is appropriate. In addition, failure to disclose medical conditions may, in certain circumstances, invalidate insurance policies such as medical insurance and life and personal accident insurance, provided to you by the Company. This is driven by their own requirements, local labour laws and where staff is recruited from. In many airlines a simple health questionnaire plus declaration is all that is required, others, depending on the type of job, require more details, for example, flight deck crew, cabin crew, engineering staff. Some airlines provide very specific additional protocols depending on the job applied for, which concentrate on gathering information about the individual’s medical status in relation to that function. Additional biometric testing may be required such as audiometry and visual acuity for those working in the noisy airside areas. The Medical Services can also provide advices on first aid and medical emergency procedures for employees including any workplace defibrillator access program. Depending on the size of the base, the number of working employees, and the local medical facilities available in the community, an in-house medical service can sometimes provide the first aid and emergency response itself.

Charleux J: Beta-carotene cheap indapamide 2.5mg with amex, vitamin C order indapamide 1.5 mg with visa, and vitamin E: the protective micronutrients purchase 2.5 mg indapamide otc, Nutr Rev 54:S109-S114 purchase indapamide 2.5 mg fast delivery, 1996 purchase indapamide 2.5 mg line. Marchioli R: Antioxidant vitamins and prevention of cardiovascular disease: laboratory, epidemiological and clinical trial data, Pharmacol Res 40:227-38, 1999. Patrick L: Beta-carotene: the controversy continues, Altern Med Rev 5:530-45, 2000. Heber D: Colorful cancer prevention: alpha-carotene, lycopene, and lung cancer, Am J Clin Nutr 72:901-2, 2000. A critical and constructive review of epidemiology and supplementation data regarding cardiovascular disease and cancer, Biofactors 7:113-74, 1998. Brighthope I: Nutritional medicine-its presence and power, J Aust Coll Nutr Environ Med 17:5-18, 1998. Lachance P: Dietary intake of carotenes and the carotene gap, Clin Nutr 7: 118-22, 1988. Although allergic responses in atopic individuals devaluate the potential benefit of proven mediations, they make use of unproven interventions intolerably hazardous. It is reputed to have soothing qualities, including calming, anti-inflammatory, and antispasmodic effects. The largest group of medically important compounds is found among the essential oils. Flavonoids, coumarins, mucilages, monosaccharides, and oligosaccharides all have beneficial effects. In a partially double-blind, randomized study Kamillosan, a cream that contains chamomile extract rich in active principles without any chamomile-related allergen potential, was found to be slightly superior to 0. In one study, chamomile was one of the aromatherapy oils used to treat children with eczema. Patzelt-Wenczler R, Ponce-Poschl E: Proof of efficacy of Kamillosan® cream in atopic eczema, Eur J Med Res 5:171-5, 2000. Mills S, Bone K: Principles and practice of phytotherapy, Edinburgh, 2000, Churchill Livingstone. Anderson C, Lis-Balchin M, Kirk-Smith M: Evaluation of massage with essential oils on childhood atopic eczema, Phytother Res 14:452-6, 2000. Despite its name and the traditional belief that the berries of the chaste tree encourage chastity, there is little evidence to suggest it decreases libido in therapeutic doses. Today the herb is used largely for women’s complaints including hot flashes, premenstrual tension, amenorrhea, and infertility. It reduces prolactin production and increases proges- terone production by reducing secretion of follicle-stimulating hormone and increasing production of luteinizing hormone. If this causes gastric irritation, the herb may be prescribed in divided doses or in capsule form. Clinical trials have demonstrated that chasteberry is effective for managing menstrual disorders, including correction of distur- bances in the length, frequency, and volume of menses. Results of a multicen- ter, open study confirmed that an extract of the fruit of the chaste tree reduced or eliminated the premenstrual syndrome symptoms of depression, anxiety, food craving, and hyperhydration. It has been suggested that 225 mg of chaste tree tea twice daily enhances milk production in breast-feeding mothers. Chasteberry contains progesterones and should not be taken in conjunc- tion with progesterone, the contraceptive pill, or hormone replacement ther- apy. It intensifies effects of dopamine antagonists and should not be used in patients receiving phenothiazides. Mills S, Bone K: Principles and practice of phytotherapy, Edinburgh, 2000, Churchill Livingstone. Diefendorf D, Healey J, Kalyn W, editors: The healing power of vitamins, minerals and herbs, Surry Hills, Australia, 2000, Readers Digest. It is a precursor for acetylcholine, phospholipid (lecithin), sphin- gomyelin, platelet-activating factor, and the methyl donor betaine. Lecithins added during food processing may increase the average intake of phosphatidylcholine by 1. At a dose of 10 g/day, cholin- ergic side effects include diarrhea, dizziness, sweating, and electrocardio- graphic changes. In its trivalent state, chromium is an essential trace element required for carbohydrate, lipid, and nucleic acid metabolism. Contrary to popular belief, chromium has not been shown to increase muscle mass or decrease body fat. Chromium increases insulin binding to cells and insulin receptor num- bers and activates insulin receptor kinase, leading to increased insulin sensi- tivity. Glucose tolerance factor is composed of trivalent chromium, two nicotinic acid molecules, and a small oligopeptide. The chromium-binding oligopep- tide chromodulin is thought to play a unique role in the auto-amplification of insulin signaling. Barley is a good source of chromium and should be included in the diet of patients with diabetes. Although higher intakes are more effective, 200 μg of supplemental chromium daily is adequate to improve glucose levels in individuals with mild glucose intolerance.