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regimen with a rapidly acting insulin analog and insulin detemir or insulin glargine that might be appropriate for a 70kg person with type 1 diabetes eating meals providing standard carbohydrate intake and moderate to low fat content Insulin glargine is usually given once in the evening to provide 24-hour coverage This insulin cannot be mixed with any of the other insulins and must be given as a separate injection There are occasional patients in whom insulin glargine does not seem to last for 24 hours, and in such cases it needs to be given twice a day As shown, insulin detemir may also need to be given twice a day to get adequate 24-hour basal coverage Alternatively, small doses of NPH (~ 3 to 4 units) can be given with each meal to provide daytime basal coverage with a larger dose at night Unlike the long-acting insulin analogs, NPH can be mixed in the same syringe as the insulin lispro, insulin aspart, and insulin glulisine Continuous subcutaneous insulin infusion (CSII) by portable battery-operated open loop devices currently provides the most flexible approach, allowing the setting of different basal rates throughout the 24 hours and permitting patients to delay or skip meals and vary meal size and composition The dosage is usually based on providing 50% of the estimated insulin dose as basal and the remainder as intermittent boluses prior to meals For example, a 70-kg man requiring 35 units of insulin per day may require a basal rate of 07 units per hour throughout the 24 hours with the exception of 3 AM to 8 AM, when 08 units per hour might be appropriate (for the dawn phenomenon) The meal bolus would depend on the carbohydrate content of the meal and the premeal blood glucose value One unit per 15 g of carbohydrate plus 1 unit.

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We ve dispensed with the Employee class to save room, but of course you can enqueue user-defined objects as well. The output shows that queuing an object adds it to the Queue, and Dequeue( ) returns the object as well as removes it from the Queue. The Queue class also provides a Peek( ) method that allows you to see, but not remove, the next element. Take a closer look at the PrintValues( ) method:

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For example, FileMerge, a GUI-based file comparison and merging program located in the /Developer/Applications folder, is implemented as a GUI application that uses the UNIX diff command, outputting its result to an ed script Later in the chapter you ll see how this works; for now, look at figure 41, which shows the result of searching the process table for the diff command as FileMerge is comparing two large files As you can see from this example, there is still a place for UNIX command-line tools in the modern age!.

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for 50 mg/dL of blood glucose above a target value (eg, 120 mg/dL) is a common starting point Further adjustments to basal and bolus dosages would depend on the results of blood glucose monitoring The majority of patients use the rapidly acting insulin analogs in the pumps One of the more difficult therapeutic problems in managing patients with type 1 diabetes is determining the proper adjustment of insulin dose when the prebreakfast blood glucose level is high Occasionally, the prebreakfast hyperglycemia is due to the Somogyi effect, in which nocturnal hypoglycemia leads to a surge of counterregulatory hormones to produce high blood glucose levels by 7 am However, a more common cause for prebreakfast hyperglycemia is the waning of circulating insulin levels by the morning Also, the dawn phenomenon reduced tissue sensitivity to insulin between 5 AM and 8 AM is present in as many as 75% of type 1 patients and can aggravate the hyperglycemia Table 27 11 shows that diagnosis of the cause of prebreakfast hyperglycemia can be facilitated by self-monitoring of blood glucose at 3 AM in addition to the usual bedtime and 7 AM measurements This is required for only a few nights, and when a particular pattern emerges from monitoring blood glucose levels overnight, appropriate therapeutic measures can be taken The Somogyi effect can be treated by eliminating the dose of intermediate insulin at dinnertime and giving it at a lower dosage at bedtime or by supplying more food at bedtime When a waning insulin level is the cause, then either increasing the evening dose or shifting it from dinnertime to bedtime (or both) can be effective A bedtime dose either of insulin glargine or insulin detemir provides more sustained overnight insulin

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