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The clinician should be aware of the limitations of the selfmonitoring glucose systems First, a few of the older meters (such as the One Touch Profile) are calibrated against whole blood glucose concentrations even though the test strip measures the glucose in the plasma fraction This means the displayed values are 10% to 15% lower than the laboratory glucose result Second, increases or decreases in hematocrit can decrease or increase the measured glucose values The mechanism underlying this effect is not known but presumably it is due to the impact of red cells on the diffusion of plasma into the reagent layer Third, the meters and the test strips are calibrated over the glucose concentrations ranging from 60 mg/dL to 160 mg/dL, and the accuracy is not as good for higher and lower glucose levels When the glucose is less than 60 mg/dL, the difference between the meter and the laboratory value may be as much as 20% Fourth, glucose oxidase based amperometric systems underestimate glucose levels in the presence of high oxygen tension This may be important in the critically ill who are receiving supplemental oxygen; under these circumstances, a glucose dehydrogenase based system may be preferable The accuracy of data obtained by glucose monitoring requires education of the patient in sampling and measuring procedures as well as in proper calibration of the instruments Bedside glucose monitoring in a hospital setting requires rigorous quality control programs and certification of personnel to avoid errors e Continuous glucose monitoring systems Three continuous glucose monitoring systems are currently available for clinical use The DexCom and MiniMed Medtronic systems involve inserting a subcutaneous sensor (rather like an insulin pump cannula) that measures glucose concentrations in the interstitial fluid for 72 hours In the MiniMed system, the measured glucose values are wirelessly transmitted to the screen of their insulin pump In the DexCom system, the data are transmitted to a separate pager-like device with a screen Both systems allow the patient to set alerts for low and high glucose values Patients still have to calibrate the devices with periodic fingerstick glucose levels, and since there are concerns regarding reliability, it is still necessary to confirm the displayed glucose level with a fingerstick glucose before making interventions such as injecting extra insulin or eating extra carbohydrates Clinical trials with these systems show that they do enable some patients to improve control without increasing the risk of hypoglycemia The individual glucose values are not that critical what matters is the direction and the rate at which the glucose is changing, allowing the user to take corrective action The wearer also gains insight into the way particular foods and activities affect their glucose levels The other main benefit is the low glucose alert warning These systems are not covered by insurance and the initial cost is about $800 to $1000, and the sensor, which has to be changed every 3 days or so, costs about $35 This adds up to an out-of-pocket expense of about $4000 annually The Glucowatch system from Animas Technologies measures glucose in interstitial fluid extracted through intact skin by applying a low electric current (reverse iontophoresis) This process can cause local skin irritation, and sweating distorts the glucose measurement For these reasons, the system is not widely used.

drowsiness, dizziness, chilliness, nausea and vomiting, facial pallor, dyspnea, and cyanosis Later, there is facial flushing, irritability, difficulty in concentrating, vertigo, tinnitus, visual disturbances, auditory disturbances, anorexia, insomnia, increased dyspnea and weakness on exertion, increased headaches (due to cerebral edema), palpitations, tachycardia, Cheyne-Stokes breathing, and weight loss More severe manifestations include pulmonary edema and encephalopathy (see below) Voluntary periodic hyperventilation may relieve symptoms In most individuals, symptoms clear within 24 48 hours, but in some instances, if the symptoms are sufficiently persistent or severe, the patient must be returned to lower altitudes Definitive treatment is immediate descent, which is essential if reduced consciousness, ataxia, or pulmonary edema occurs Administration of oxygen, 1 2 L/min, will often relieve acute symptoms If immediate descent is not possible, portable hyperbaric chambers can provide symptomatic relief depending on altitude and severity Acetazolamide, 250 mg orally every 8 12 hours, or dexamethasone, 8 mg orally initially followed by 4 mg every 6 hours, for as long as symptoms persist, is recommended therapy; they may be used together in severe cases Preventive measures include slow ascent 300 meters (984 feet) per day adequate rest and sleep the day before travel, reduced food intake, and avoidance of alcohol, tobacco, and unnecessary physical activity during travel Acetazolamide, 250 mg orally every 8 12 hours, beginning the day before ascent and continuing for 48 72 hours at altitude, may be used as prophylaxis Dexamethasone, 4 mg orally every 12 hours beginning on the day of ascent, continuing for 3 days at the higher altitude, and then tapering over 5 days, is an alternative

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Another form of insuring against credit risks is payment guarantees These are used as a guarantee against a value to be billed to a customer They take the form of a payment guarantee procedure Examples are documentary payment guarantees (such as a confirmed letter of credit), payment cards, and export credit insurance

Five manifestations of altitude illness are (1) acute mountain sickness, (2) high-altitude pulmonary edema, (3) high-altitude encephalopathy, (4) subacute mountain sickness, and (5) chronic mountain sickness (Monge s disease)

This serious complication usually occurs at levels above 3000 meters (9840 feet) Early symptoms may appear within 6 36 hours after arrival at a high-altitude area: incessant dry cough, shortness of breath disproportionate to exertion, headache, decreased exercise performance, fatigue, dyspnea at rest, and chest tightness Later, wheezing, orthopnea, and hemoptysis may occur Recognition of the early symptoms may enable the patient to descend before incapacitating pulmonary edema develops, but strenuous exertion should be avoided An early descent of even 500 or 1000 meters may result in improvement of symptoms Physical findings include tachycardia, mild fever, tachypnea, cyanosis, prolonged respiration, and rales and rhonchi The patient may become confused or comatose, and the clinical picture may resemble severe pneumonia The white count is often slightly elevated, but the erythrocyte sedimentation rate is usually normal Chest radiographic findings vary from irregular patchy infiltration in one lung to nodular densities bilaterally or with transient prominence of the central pulmonary arteries Transient nonspecific ECG changes, occasionally showing right ventricular strain, may occur Pulmonary arterial blood pressure is elevated, whereas wedge pressure is normal Treatment, which must often be given under field conditions, consists of rest in the semi-Fowler position (head raised) and administration of 100% oxygen by mask

Lack of sufficient time for acclimatization, increased physical activity, and varying degrees of health may be responsible for the acute, subacute, and chronic disturbances that result from (hypobaric) hypoxia at altitudes greater than 2000 meters (6560 feet) Acclimatization to altitudes above 5500 m (18,045 ft) is incomplete or physiologically impossible, although individual differences in tolerance to hypoxia exist Altitude exacerbated conditions include cardiac and pulmonary dysfunction and disease, sickle cell, high-risk pregnancy, radial keratotomy, and others

The severity of acute mountain sickness (AMS) correlates with altitude and rate of ascent Initial manifestations include headache (most severe and persistent symptom), lassitude,

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