Management of Diabetic Foot Ulcers

Management of Diabetic Foot Ulcers Diabetic foot disorders are the rated as the number one cause of hospitalisation for diabetic mellitus patients in the United States and abroad. Among these disorders are, foot infection, ulcerations, cellulitis and gangrene. It is estimated that a 100 people per week lose a digit, foot or a lower limb due to diabetes mellitus8. Diabetic foot disorders and its long term complications account for direct medical budget of hundreds of millions of dollars annually, including lengthy hospital stay of patients and lengthened periods of disability. In the UK, diabetes cost the NHS over  £5 million pounds per annum and the cost of diabetic foot complications including amputations was  £252 million in 2003. Figures show that 1 in 10 foot ulcers result in the amputation of a foot or a leg. The most distinguishing foot complication of diabetes is the ulcer, which is of course a major risk factor for amputation. Mortality rates after amputation are as high as 50 percent in diabetic patients. Although the primary pathogenesis is neuropathy, immunopathy and vasculopathy (ischemia), diabetic foot ulcer is attributed to a number of other risk factors. Early detection of these risk factors as well as the foot ulcers themselves is crucial in the general management of diabetic foot ulcers and amputation prevention. Therefore, immediate and aggressive treatment of all diabetic foot ulcers can prevent worsening of the complication and the need for amputation. The objective of treatment as a result should be prompt intervention to allow good healing of the ulcer and once healed, to prevent its recurrence. However, the optimum care for foot ulcers rest upon the treatment teams understanding of the pathophysiology associated with diabetic foot ulcers, familiarity with current methods of treatment and the concept that the multidisciplinary team approach is the gold standard in preventing limb amputation. And above all, prevention of foot lesions should be ranked highest amongst all priorities. EPIDERMIOLOGY There is no concrete data illustrating the true picture of the incidence and prevalence of diabetic foot ulcers. However, majority of the information gathered about its aetiology is based upon national hospital discharge survey (NHDS) data, which does not include a vast number of patients with ulcerations treated on the outpatient basis. Cross-sectional and population-based studies help to approximate the distribution and frequency of diabetic foot ulcers, while prospective cohort studies and retrospective case-control studies are instrumental in detecting associated risk factors for the foot lesions. According to Reiber et als epidemiological review, chronic ulcers represented 2.7% of all diabetes related admissions and 46% of all admissions due to any ulcer condition. The 1983-1990 NHDS survey also revealed that the highest ulcer rates were found in individuals aged 45-64 years, with male preponderance over the female. The average length of stay (LOS) for diabetes pat ients discharged with ulcers was 59% more than in patients without ulcers, around 14 and 8 days, respectively. Numerous population-based studies record a yearly incidence of diabetic foot ulcers in the magnitude of 2% 3% in both type 1 diabetes mellitus (IDDM) and type 2 diabetes mellitus (NIDDM) patients, while the prevalence ranges between 4% and 10%. These studies also suggest a widespread trend for higher prevalence of ulcerations with increasing age and duration of diabetes. Once ulcerations have occurred, recurrence rate can get to 50% in 2 years and 70% in 5 years. Despite the fact that mortality linked with diabetic foot ulcerations has not been recorded, 70% to 80% of amputations of the lower extremity can be lead by foot ulcers. Amputation is one of the most common sequels in persons with diabetes mellitus now exceeds 100,000 per year in the United States and amputations involving the leg, foot or toe(s) are not uncommon. Approximately 15% of patients with diabetic foot u lceration will require amputations due to uncontrolled infection, gangrene or failure of the ulcers to heal. Unfortunately, there is a 3-year survival rate of 50% after the amputation of a lower limb, while the 5-year survival rate is approximately 40%. Subsequently, less than half of the patients who end up with lower extremity amputation (LEA) of one limb go on to develop a severe contralateral ulcer within a space of 2 years, thereby putting the future of the other limb at risk as well. AETIOLOGY/PATHOPHYSIOLOGY Several factors have been implicated in association with diabetic foot ulcers. These factors include the intrinsic complications of diabetes mellitus in affiliation with some extrinsic factors and together predispose the diabetic patient to the risk of developing foot lesions. The trilogy of peripheral neuropathy, peripheral arterial disease (ischemia) and susceptibility to infection (immunopathy) are the main predisposing factors for lesions on the foot. The impact of peripheral neuropathy may not be easily detectable, with little or no signs and symptoms. Notwithstanding, its pathology advances fast and the end stage of tissue necrosis quickly reached. Distal sensory neuropathy can be seen in 20% to 50% of patients with type 2 diabetes. This decreases the protective sensation in the feet, leading to abnormal spreading of foot pressure and shear stresses with subsequent callus formation. This in turn diminishes the patients ability to perceive minor trauma to the foot and this is de monstrable by vibration perception threshold (VPT) and insensitivity to a 10g monofilament, which conveys a 7-fold and 18-fold risk of foot ulceration respectively. Distal motor neuropathy precedes atrophy of the intrinsic and extrinsic musculature of the foot, with accompanying deformities of the toes and metatarsals heads on the plantar aspects of both feet and consequent bunions on the 1st and 5th metatarsal-phalangeal joints. However, these irregularities of the feet cause an increase in the foot pressures, particularly around the bony prominences, thus resulting in more calluses forming. These calluses then go on to further increase the local subcutaneous pressure, ultimately resulting into haemorrhage beneath the callus, a lesion known as the pre-ulcer is then formed. With progressive pressure mounting on the pre-ulcer, the overriding skin breaks down to produce an ulcer. In addition, distal autonomic neuropathy could as well spark a plantar ulcer directly by reducing sweating in the feet with consequent drying and cracking of the skin28.Peripheral arterial disease and impaired cutaneous circulation are also important risk factors for both ulcerations and LEA. Peripheral arterial ischemia sometimes produces ischemic ulcers, but these are rare occurrences i.e. (1% 2% incidence) than neuropathic ulcers (65%) or combined neuroischaemic ulcers (25%) 28. Transcutaneous oxygen tension (Tc pO2) levels less than 30mmHg and absence of peripheral pulses or past history of vascular surgery are strong separate predictors of ulceration. Diabetic foot infections often set in and complicate already settled foot ulcers. Although, infections play an integral part in the pathway to lower limb amputation, there is inconclusive data with regards to the position of susceptibility to infection in causing ulceration. Even though, most ulcers are caused by minor foot trauma, and in some cases the patient takes no notice of because of the sensory neuropathy. These minor injuries (i.e. extrinsic factors which include; wearing ill-fitting/brand new shoes, hot soaks occupational hazards and to a lesser extent self-induced trauma by cutting toe nails or calluses) constitute the leading cause of acute precipitant of diabetic foot ulcers. In addition, there are also a number of intrinsic factors which could predispose diabetics to developing foot ulcers and they include; longstanding diabetes, past history of ulcers or amputation, age, weight, retinopathy, nephropathy and structural deformities of the foot (i.e. Charcot foot) have al l been associated as risk factors for ulcerations. However, bad biomechanical function arising from the complications of diabetes generally leads to foot injuries in most diabetic patient. ASSESSMENT OF DIABETIC FOOT ULCERS A detailed and well organised evaluation of the lower extremities is crucial when commencing the treatment of a diabetic foot ulcer. Before carrying out the physical examination of the limbs, it is noteworthy to perform a quick inspection of the patients shoes for good fit, foreign objects and the wear and tear patterns. The clinical evaluation must include an appropriate assessment of the ulcers aetiology, its extent and depth, presence and severity of both local and systemic infection and peripheral vascular status. A comprehensive assessment of the patients general health and glycaemic control, extent of peripheral neuropathy, a careful, yet detailed dermatologic and musculoskeletal examination should also be included in the evaluation. These assessments determine the ulcers healing rate, potential progression to LEA, and the likelihood of reoccurrence. Therefore, they should be accomplished urgently in the ambulatory or hospital setting and require a multidisciplinary team approach, with possible consults to the infectious disease specialist, podiatry, vascular and orthopaedic surgeons. Bilateral lower limb pulses must be examined. When pulses are diminished or not palpable, Doppler segmental pressures to the toes or TcpO2 measurement are indicated and the vascular experts should be brought on broad. The neurological evaluation should assess the patients sensorium and deep tendon reflexes. The ankle and knee reflexes are tested with the aid of a simple neurological hammer, while the important aspects in the evaluation of the sensorium are: reduced sensation to pain, light touch, hot/cold and vibratory sensation. Pain sensation is easily assessed with a disposable needle. A piece of cotton ball, lambs wool or 10-g monofilament can be used to evaluate the light touch and a 128-Hz or 512-Hz tuning fork or biothesiometer are approved for vibratory evaluation. Cold perception is also assessed by submerging the metal arm of a neurological hammer into cold water and then placing it against the patients skin. Anatomical deformities such as hammertoes, previous foot amputation, or Charcot joints often produce high pressure areas which result in ulceration. The musculoskeletal evaluation cannot be done by visual inspection of structural findings alone, it must also include testing for muscle strength, weakness, atrophy and contracture. Assessment of joint range of movement and gait evaluation with computerised plantar pressure analysis will also be of great value in appreciating the abnormal dysfunction contributing to ulceration. Examination of the skin of both feet is also carried out with detailed attention to the quality and integrity of the skin around the interdigital areas. Changes in the colour of the skin often associated with spotted rashes and heel fissures are suggestive of a significant level of ischemia. Toenail changes and presence of subungual drainage are pointers to a proximal source of infection. Clinical assessment of the ulcer should include a detailed description of its appearance as well as the measurement of the ulcers diameter with a wound measuring guide. Outlines of the ulcer on a translucent film or plastic sheet can also promote this process. This must be documented and retraced at subsequent visits to assess the treatment process. The depth and extent of the wound should be carefully explored with a blunt sterile probe. Special care must be taken to probe for hidden sinus tracts and subcutaneous abscesses or to identify tendon, bone or muscle or joint involvement. Ulcer depth is a significant predictor of healing rate, possibility of concurrent osteomyelitis and the chances for amputation. The presence of infection is a huge cause of the need for hospitalization. Therefore, a general assessment with physical examination, laboratory investigations and radiographic studies is important in classifying infection as absent, mild, moderate or severe. This classification acts as a guide to determine or select the initial antibiotic therapy and to decide when to hospitalise the patient. Clinical signs of infection such as purulent discharge, odour, cellulitis, fever and leucocytosis must be documented. However, Leucocytosis and fever might not always be noticeable even in the presence of acute osteomyelitis. Approximately 54% of patients with diabetic foot infections had normal white blood cell count and no fever44. Bacteria cultures of anaerobes and aerobes (both gram positive and gram negative) should be obtained from the base of the ulcer, bone or blood or from all three depending on the clinical setting. This helps in clarifying the true hidden pathogens and may facilitate the decision to adjust initial antibiotic therapy. Physical examination of signs of infection in the patient centers on the presence or absence of systemic responses such as fever, tachycardia, sweats or hypotension and the appearance of the wound and adjacent tissues. Early signs of infection are evident by increased amount of exudates from the wound, base of the ulcer changes from pink granulation to yellowish- grey tissue, tenderness and induration around the ulcer. Infection should be considered severe when the patient present with systemic toxicity, signs of fascilitis or a rim of erythema around the ulcer greater than 2cm in diameter. Laboratory investigation to confirm the presence of infection should include white blood cell count and differential which could show leucocytosis or a shift to the left or both, erythrocyte sedimentation rate (ESR) which when elevated above 40mm/hr is a strong indicator of osteomyelitis28. In addition, glucose, bicarbonates and creatinine levels are tested to rule out possible hyperglycaemia, metabolic acidosis or azotemia from dehydration which strongly suggest the presence of a severe infection. Radiological evaluation should be obtained promptly to ascertain the presence of fractures, foreign objects or signs of osteomyelitis. Plain x-rays have a low sensitivity, thus they should be interpreted with caution as changes in the foot caused by Charcot foot could mirror those osteomyelitis when seen on a plain x-ray. However, a normal plain x-ray of the foot does not rule out osteomyelitis, a repeat should be requested 2 weeks later to exclude occult osteomyelitis. As indicated, other imaging modalities can aid in the diagnosis of osteomyelitis such as CT scans, magnetic resonance scan (MRI) or leukocyte scans and each having their own strengths and limitations. TREATMENT Management of the foot ulcer is mostly determined by its severity, vascularity and the presence of infection1. Recognition of its root cause will serve as a guide during the course of treatment. However, a multidisciplinary team consisting of specialist from podiatry, orthopaedic surgery, vascular surgery, the infectious disease service and diabetic education service should be involved in the management. The multidisciplinary team approach is due to the complicated nature of the disease itself as well as managing the various comorbidities associated with foot ulcers. In addition, the approach has been demonstrated in clinical trials to produce significant outcomes in terms of improvement and reduce the incidence of major amputations. The wound should be immediately relieved of all pressures, elevated and rested at first presentation. Effective local wound care must be carried out and ill- fitting footwear should be discarded and replaced with appropriate surgical or relief shoes for protection. And in cases where total nonweightbearing with crutches is impossible, a pressure felt padding or foam can be used in the surgical shoes. However, the total contact cast (TCC) is considered gold standard to protect neuropathic ulceration during ambulation due to its ability to eliminate high pressure areas under the foot. Adequate alternatives to the TCC are the Scotchcast Boot or removable walking braces. Treatment of hyperglycaemia, ketoacidosis, renal insufficiency and other comorbidities that may coincide in the ulcerated patient should be treated simultaneously with the foot lesion. Consultations to internal medicine, endocrinology and cardiology are generally frequent when managing acutely infected patient who need to be hospitalised. Such consultations are usually sought early in course of treatment to ensure good metabolic control. Diabetic foot infections are usually polymicrobial and as such initial antibiotic therapy should be broad-spectrum after obtaining good aerobics and anaerobic culture samples. Antibiotic therapy should be later modified according to the culture and sensitivity test and the patients clinical response to the initial therapy. Surgical debridement and drainage or local partial amputations are crucial adjuncts to antibiotic therapy. Underlying osteomyelitis usually present in moderate to severe infections and often requires aggressive bony resection of infected bone and joints accompanied by cultured -directed antibiotics for 4 6 weeks. Foot ulcer patients with underlying ischemia should undergo revascularization with angioplasty or vascular bypass procedure if its anatomically possible. Even with severe distal arterial obstruction, revascularization to return pulsation to the foot is a major part of the limb-salvage strategy and may be accomplished in such patients. However, where revascularization is not feasible or in cases of advanced infection or extensive necrosis, amputation at some level may be required. Wound care is also necessary after surgical or sharp debridement of all callus and necrotic tissue58. Practically, a warm, moist environment conducive for wound healing should be maintained.This can be arranged using saline wet/dry dressings or special dressings such as semipermeable films, hydrogels, calcium alginates and hydrocolloids. Tissue-engineering dermis is a more recent class of biologic dressing and has been tested to be more effective than saline dressings. There is little evidence to support the role of topical enzymes and should be avoided. Although the role of topical growth factors in the healing rate of ulcers is beneficial, however, they are expensive and should be limited to patients whose ulcers cease to improve after 4-6 weeks of adequate therapy. PREVENTION OF RECURRENCE AND AMPUTATION Prevention is regarded as a major aspect in avoiding ulcer relapse and diabetic lower limb amputation. Recurrence rate with diabetic foot ulcers and LEA are as high as 50% -70% over three years. Comprehensive intervention programs tailored to individual patients can lower these rates and can be accomplished with a multidisciplinary team approach. Control of both macrovascular and microvascular risk factors is also of great importance. Patient education and re-education plays a primary, yet active role in this program and involves instruction in foot hygiene, the need for daily inspection, proper footwear and the necessity of prompt treatment of new lesions. In addition, regular and frequent visit to a diabetic foot care program is crucial. The feet must be thoroughly inspected at every visit and should include debridement of calluses and ingrown toenails. This provides an excellent opportunity to back up self care behaviour as well as allowing early detection of new or imminent foot problems. Appropriate therapeutic footwear with pressure-relieving insoles and high toe box which protect the high risk foot are an essential element of the prevention program and have been associated with significant reductions in ulcer development. Subsequently, patients with major structural deformities may benefit from reconstructive surgery to prevent recurrent foot ulcers. Surgery may be especially suitable in patients who cannot be accommodated in therapeutic footwear. And because patients with healed ulcers are at risk for future ulceration, these preventive measures must be integrated into a long life strategy and treatment program. CONCLUSION Diabetic foot ulcerations, infections, gangrene and lower extremity amputations (LEA) are major causes of disability to patients with diabetes mellitus. And these often results in extensive periods of hospitalisation, substantial morbidity and mortality. Although not all such lesions can be prevented, it is certainly possible to reduce their incidence by proper management and prevention programs. A multidisciplinary team approach to diabetic foot disorders has been regularly proven to be the best method in achieving favorable rates of limb salvage in this high risk population. Foot care programs accentuating preventive management can reduce the incidence of foot ulceration through modification of self care practices, appropriate evaluation of risk factors and formulation of treatment protocols directed at patient education/re-education, early intervention, limb preservation and prevention of new lesions. The joint team of medical, surgical, rehabilitative and footwear specialist shou ld impart effective and coordinated services for acutely infected or ischemic inpatients as well as management for the outgoing patients. In general, the incidence and morbidity of diabetic limb amputations can be reduced if the above principles are embraced and integrated into everyday patient management protocol.

Absolute Time Essay

Instructions (Q 7-Q 16): Read the following passage carefully and answer the questions given below it. â€Å"Life is not just party and pleasure; it is also pain and despair. Unthinkable things happen. Sometimes everything turns upside down. Bad things happen to good people. Some things are beyond control, such as physical disability and birth defects. We cannot choose our parents or the circumstances of our birth. So if the ball bounced that way, sorry. But what do we do from here; cry or take the ball and run? That is a choice we have to make. On a clear day, there are hundreds of boats sailing in all different directions in a lake. How come? Even though the wind is blowing in one direction, the sailboats are going in different directions. What is the difference? It depends on the way the sail is set, and that is determined by the sailor. The same is true of our lives. We can’t choose the direction of the wind, but we can choose how we set the sail. We can choose our attitude even though we cannot always choose our circumstances. The choice is either to act like a victor or a victim. It is not our position but our disposition that determines our destiny. It takes both rain and sunshine to create a rainbow. Our lives are no different. There is happiness and sorrow. There is the good and the bad; dark and bright spots. If we can handle adversity, it only strengthens us. We cannot control all the events that happen in our lives, but we can control how we deal with them. Richard Blechnyden wanted to promote Indian tea at the St. Louis World fair in 1904. It was very hot and no one wanted to sample his tea. Blechnyden saw that all the other iced drinks were doing flourishing business. It dawned on him to make his tea into an iced drink, mix in sugar and sell it. He did and people loved it. That was the introduction of iced tea to the world. When things go wrong, as they sometimes will, we can react responsibly or resentfully. Human beings are not like an action which has no choice. An action cannot decide whether to become a giant tree or to become food for the squirrels. Human beings have choices. If nature gives us a lemon, we have a choice: either cry or make lemonade. † 7. â€Å"We cannot choose our parents or the circumstances of our birth† – by this statement what does the author mean? (a) Some things do not take place according to our choice (b) There are certain things in which we do not have any reach (c) Some things in this world are pre-determined. (d) All of the above Ans. (d) 8. By what the author tells us that choice is ours? (a) We can cry (b) We can take the ball and run away (c) We can either cry or can take the ball and run away (d) None of the above Ans. (c) 9. The opposite of the word ‘victor’? (a) Loser (b) Winner (c) Victim (d) Warrior Ans. (a) 10. What determines our destiny? (a) The way that we normally think and behave, that shows what type of person we are (d) The position we hold (c) Our being a winner (d) All of the above Ans. (a) 11. The best title for the above passage could be – (a) Right Choice (b) Pre-determination. (c) Choices defines our lives (d) Life is all about making the right choices Ans. (d) 12. According to the author, what still can be chosen if not everything in life? (a) Circumstances (b) Attitude (c) direction of life (d) None of these Ans. (b) 13. On what has the author emphasized? (a) Destiny (b) Choice (c) Action (d) All of these Ans. (b) 14. By the example of Blechnyden’s Iced Tea which message does the author give? (a) Choice is ours (b) Destiny is pre-determined (c) We have fix actions; we can not do beyond that (d) None of the above Ans. (a) 15. What does actually strengthen us? (a) Making choices (b) Handling adversity (c) Determining destiny (d) Working beyond capacity Ans. (b) 16. The synonym of ‘flourishing’ is – (a) Spoiling (b) Drowning (c) Booming (d) Hiding Ans. (c) 17. During a 5-day festival, the number of visitors tripled each day. If the festival opened on a Thursday with 345 visitors, what was the attendance on that Sunday? (a) 345 (b)1,035 (c)1,725 (d) 9,315 Ans. (d) 18. Which of the following has the least value? (a) 0. 27 (b) 1/4 (c) 3/8 (d) 11% Ans. (d) 19. Which year did the same number of boys and girls attend the conference? (a) 1995 (b) 1996 (c) 1997. (d) 1998 Ans. (a) 20. Which two years did the least number of boys attend the convention? (a) 1995 and 1996 (b) 1995 and 1998 (c) 1996 and 1997 (d) 1997 and 1994 Ans. (a) 21. Examine the following three statements : 1. Proceesed meat is a perishable food 2. All perishable foods are packed in sealed tins 3. Sealed tins sometimes to do not contains processed meat Which one of the following inferences can be drawn from the above statements? (a) Sealed tins always contain perishable food (b) Processed meat is sometimes not packed in sealed tins (c) Proceessed meat is always packed in seald tins. (d) Non-Perishable foods are never packed in seald tins Ans. (c) 22. Production of Rice and Wheat (In millions of Tonnes)| | Year| Rice| Wheat| Percentage of Wheat to Rice| 1950-51| 20. 58| 6. 46| 31. 4| 1960-61| 34. 58| 11. 00| 31. 8| 1970-71| 42. 22| 23. 83| 56. 4| 1980-81| 53. 63| 36. 31| 67. 7| 1990-91| 74. 29| 55. 14| 74. 2| 1994-95| 81. 81| 65. 77| 80. 4| 1995-96| 79. 62| 62. 62| 78. 6| The above table indicates the performance in India in rice and wheat production from 1950-51 to 1995-96. Which of the following conclusions arrived at from the above table would be valid? 1. Record production of rice as well as wheat has been in 1994-95 2. The ratio of wheat to rice production seems to have steadily increased over 16 years 3. Wheat has not been popular among the Indian population before 1980. 4. India became self-sufficient in rice and wheat only after 1990. Select the correct answer using the codes given below Codes: (a) 1 and 2 (b) 1, 2, 3 and 4 (c) 3 and 4 (d) None Ans. (a) 23. A father left a will of Rs. 35 lakhs between his two daughters aged 8. 5 and 16 such that they may get equal amounts when each of them reach the age of 21 years. The original amount of Rs. 35 lakhs has been instructed to be invested at 10% p. a. simple interest. How much did the elder daughter get at the time of the will? (a) Rs. 17. 5 lakhs (b) Rs. 21 lakhs (c) Rs. 15 lakhs (d) Rs. 20 lakhs Ans. (b) 24. What will Rs. 1500 amount to in three years if it is invested in 20% p. a. compound interest, interest being compounded annually? (a) 2400 (b) 2592 (c) 2678 (d) 2540 Ans. (b) 25. What is the area of the largest triangle that can be fitted into a rectangle of length aâ‚ ¬? laâ‚ ¬Ã¢â€ž ¢ units and width aâ‚ ¬? waâ‚ ¬Ã¢â€ž ¢ units? (a) lw/3 (b) (2lw)/3 (c) (3lw)/4. (d) (lw)/2 Ans. (d) 26. Which of the following is inCorrect? (a) An incentre is a point where the angle bisectors meet. (b) The median of any side of a triangle bisects the side at right angle. (c) The point at which the three altitudes of a triangle meet is the orthocentre (d) The point at which the three perpendicular bisectors meet is the centre of the circumcircle. Ans. (b) 27. How long will it take for a sum of money to grow from Rs. 1250 to Rs. 10,000, if it is invested at 12. 5% p. a simple interest? (a) 8 years (b) 64 years (c) 72 years (d) 56 years Ans. (d) 28. Rs. 5887 is divided between Shyam and Ram, such that Shyamaâ‚ ¬Ã¢â€ž ¢s share at the end of 9 years is equal to Ramaâ‚ ¬Ã¢â€ž ¢s share at the end of 11 years, compounded annually at the rate of 5%. Find the share of Shyam. (a) 2088 (b) 2000 (c) 3087 (d) None of these Ans. (c) Directions (Q 28-Q 32): Study the following information carefully to answer these questions. Eight members A, B, C, 0, E, F, G and H belonging to three families X, Y, Z go for weekend outing in three different cars I, II, III. Four out of the eight members are females. Members of any one family travel in different cars. Each car has at least one male and one female member. Each family has at least two members. A belongs to family Y and he travels in car III. D is wife of E and they travel in cars I and II respectively. H is son of B, who is wife ofG, and they belong to family Z. C is daughter of F, who is wife of A. C travels in car II. G does not travel with F. 29. Which of the following groups of persons travels in car I? (a) 0, F,G (b) D,E,G (c) D,G, H (d) D, F, H Ans. (d) 30. Which of the following members of families Y and Z travel in different cars? (a) F,G (b) C,G (c) F,H (d) None of these. Ans. (a) 31. Which of the following groups of persons is a group of all females? (a) B,D,G (b) A,B,C (c) B,E,F (d) None of these Ans. (d) 32. Which of the following members of families X and Y travel in the same car? (a) C,F (b) D,F (c) C,0 (d) F, E Ans. (b) 33. When a student weighing 45 kgs left a class, the average weight of the remaining 59 students increased by 200g. What is the average weight of the remaining 59 students? (a) 57 kgs (b) 56. 8 kgs (c) 58. 2 kgs (d) 52. 2 kgs Ans. (a) 34. Three math classes: X, Y, and Z, take an algebra test. The average score in class X is 83. The average score in class Y is 76. The average score in class Z is 85. The average score of all students in classes X and Y together is 79. The average score of all students in classes Y and Z together is 81. What is the average for all the three classes? (a) 81 (b) 81. 5 (c) 82 (d) 84. 5 Ans. (b) 35. The average of 5 quantities is 10 and the average of 3 of them is 9. What is the average of the remaining 2? (a) 11 (b) 12 (c) 11. 5 (d) 12. 5 Ans. (c) 36. A stairway 10ft high is such that each step accounts for half a foot upward and one-foot forward. What distance will an ant travel if it starts from ground level to reach the top of the stairway? (a) 30 ft (b) 33 ft (c) 10 ft (d) 29 ft Ans. (d) 37. Each interior angle of a regular polygon is 120 degrees greater than each exterior angle. How many sides are there in the polygon? (a) 6 (b) 8 (c)12 (d) 3 Ans. (c) 38. A and B are two points with the co-ordinates (-2, 0) and (0, 5). What is the length of the diagonal AC if AB form one of the sides of the square ABCD? (a) units (b) units (c) units (d) units Ans. (b) 39. The average weight of a class of 24 students is 36 years. When the weight of the teacher is also included, the average weight increases by 1kg. What is the weight of the teacher? (a) 60 kgs (b) 61 kgs (c) 37 kgs (d) None of these Ans. (b) 40. The average of 5 quantities is 10 and the average of 3 of them is 9. What is the average of the remaining 2? (a) 11 (b) 12 (c) 11. 5 (d) 12. 5 Ans. (c) Instruction (Q. 40-Q 43): Four question given below are based on the following information. Answer the questions after reading the information carefully. (i) Nine friends A, B,C, D, E, F, G, H, and I are sitting on a bench in the classroom. (ii) ‘C’ who is at immediate right of ‘D’ is third to the right of ‘E’. (iii) ‘B’ is at one end. (iv) ‘H’ is nearest neighbour of ‘F’ and ‘G’ (v) ‘F’ is third to the left of ‘B’ (vi) ‘A’ is at immediate left of ‘F’ 41. Which of the following statement is correct on the basis of above order of sitting? (a) D and H Have three people sitting between them. (b) ‘B’ is fourth to the right of F. (c) ‘I’ is at immediate left of A. (d) E and C are Neighbours. Ans. (a) 42. Which of the following groups of friends is sitting at the left of ‘C’? (a) BIG (b) AFH (c) EID (d) BAG Ans. (c) 43. Which of the following is at the other end i. e. other that that end on which ‘B’ is sitting? (a) G (b) H (c) I (d) E Ans. (d) 44. Who is sitting exactly in the middle of the bench? (a) H (b) C (c) A (d) G Ans. (c) 45. A 400 meter long train crosses and 800 meter long platform in 1 min 20 sec. What is the speed of the train? (a) 48 km/hr (b) 60 km/hr (c) 72 km/hr (d) 54 km/hr Ans. (d) 46. If the root of equation px2 + qx +r = 0 is double of the other root, which one the following is correct? (a) 2 q2 = 9 pr (b) 2 q2 = 9 (c) 4 q2 = 9 r (d) 9 q2 = 2 pr Ans. (a) 47. A takes 4 days and B takes 5 days to finish a job. If both of them work together on the same job, what proportion of the work is done by A? (a) 4/9 (b) 5/9 (c) 6/9. (d) 7/9 Ans. (b) 48. The 3rd term of a Geometric progression is 36 and its 6th term is 288. Its 8th term will be: (a) 784 (b) 576 (c) 1152 (d) 2302 Ans. (c) 49. In a two digit number, the sum of the digits is 8. If 54 is subtracted from this number, its digits interchange themselves. What is the product of the digits of the number? (a) 7 (b) 12 (c) 16 (d) 0 Ans. (a) 50. The difference between simple interest and compound interest on certain amount for 2 years at the same rate of interest is Rs. 18. If the rate doubled, what will be the difference? (a) Rs. 9 (b) Rs. 36 (c) Rs. 72 (d) Rs. 27 Ans. (c) 51. A dog is tied to a pole by a long chain. Keeping the chain fully stretched, the dog moves along a circular path covering 132 m, subtends an angle of 90 degree at the centre, Neglecting the portion of the chain used in typing, find the length of the chain. (a) 70 m (b) 78 m (c) 84 m (d) 88 m Ans. (c) 52. A merchant buys same quantities of two types of toys – one at the rate of 3 toys for Rs. 10 and the other, at the rate of 5 toys for Rs. 20. At what price he must sell all the toys so that he has no profit and no loss in the transaction? (a) 8 toys for Rs. 30 (b) 3 toys for Rs. 11 (c) 5 toys for Rs. 18. (d) 8 toys for Rs. 22 Ans. (b) 53. Find the equation of a line whose intercepts are twice of the line 3x – 2y – 12 = 0 (a) 3x – 2y = 24 (b) 2x – 3y = 12 (c) 2x – 3y = 24 (d) None of these Ans. (a) 54. The difference between the compound interest and the simple interest on a certain sum at 12% p. a. for two years is Rs. 90. What will be the value of the amount at the end of 3 years? (a) 9000 (b) 6250 (c) 8530. 80 (d) 8780. 80 Ans. (d) 55. Vijay invested Rs. 50,000 partly at 10% and partly at 15%. His total income after a year was Rs. 7000. How much did heinvest at the rate of 10%? (a) Rs. 40,000 (b) Rs. 40,000. (c) Rs. 12,000 (d) Rs. 20,000 Ans. (b) 56. The average weight of a class of 24 students is 36 years. When the weight of the teacher is also included, the average weight increases by 1kg. What is the weight of the teacher? (a) 60 kgs (b) 61 kgs (c) 37 kgs (d) None of these Ans. (b) Instructions for the following Question: Read the following information to answer the question given below. The following conditions have been decided for the selection of Research Assistants. The candidate must: (i) Be less than 35 years of age. (ii) Be graduate in Psychology, Education or Commerce or Postgraduate in any other subject. (iii) Secure 50% marks in entrance examination. (iv) Secure A or O grade in Interview. (v) Have passed a certificate course in Methodology Research. (vi) Have recommendation of any one lecturer. If a candidate fulfills all the conditions, except (a) (i), but if he is registered for Ph. D. , his case is to be kept in waiting list. (b) (iii), but if he has secured 45% marks in entrance examination and O grade in interview, his case is to be referred to the Dean. (c) (v), but if he has qualified certificate course in Statistics, his case is to be referred to the Head Of Department. You have to decide in each of the following cases that what is the possibility of selection of the candidate? If the information is not sufficient to take any decision then your answer will be ‘data inadequate’. This information has been given to you as on 15. 12. 1996. 57. Raman has secured 60% marks in graduation with commerce subject. He has got specialization in certificate course in Methodology Research and he also has the recommendation from the lecturer under whom he is registered for Ph. D. His date of birth is 9. 12. 61. He has secured 68% marks in entrance examination and got A grade in interview. (a) Will not be selected. (b) Data inadequate (c) Will be selected. (d) Will be kept in waiting List. Ans. (d) 58. ’ means ‘–’; ‘–’ means ‘x’; ‘x’ means ‘+’ and ‘+’If ‘ 80 – 40 + 20 = ? ’, then 40 ? 120 means ‘ (a) 80 (b) 120 (c) 60 (d) 0 Ans: (d) 59. A businessman makes a profit of 20% on the sale of leather. If he were to add 10% artificial matter to the leather, by what percent would his profit increase? (a) 25% (b) 60% (c) 40% (d) 45% Ans. (b) 60. In a team, eight boys play Chess. The remaining boys, who represent 7 times the square root of the strength of the tem, play Mouth organ. What is the strength of the team? (a) 36 (b) 16 (c) 64 (d) 100 Ans. (c) 61. Cost price of 15 Computers is equal to the selling price of 20 Computers, then the loss percent would be (a) 25% (b) 20% (c) 30% (d) 45% Ans. (a) 62. How many natural numbers between 1 and 900 are not multiples of any of the numbers 2, 3, or 5? (a) 240 (b) 250 (c) 270 (d) 300 Ans. (a) 63. The age of a man is three times the sum of the ages of his two sons. Five years hence, his age will be double of the sum of the ages of his sons. The father’s present age is (a) 40 years (b) 45 years (c) 50 years (d) 55 years. Ans. (b) Instruction (Q 62-Q 63): In the two questions given below, a statement followed by two arguments I and II has been given. You have to decide which argument is strong and which one is weak? Give your answer as: (a) If only argument I is strong; (b) If only agreement II is strong; (c) If neither argument I nor argument II is strong; (d) If both argument I and argument II are strong. 64. Statement: Should freelance work programme be stopped at private companies? Argument: I. Yes, the mutual interaction of the employee and office environment helps in overall quality of work. II. No, such demand comes from that group only who don’t have any idea of work loads and pressure. Ans. (d) 65. Statement: Should usage of pesticides in agriculture be banned in India? Agriculture be banned in India? Arguments: I. Yes, because pesticides pollute the environment and are also harmful for the ecology. II. No, the safety of crops is not possible without these and food products will become very expensive due to lack of food production. Ans. (d) 66. If the numbers representing volume and surface area of a cube are equal, then the length of the edge of the cube in terms of the unit of measurement will be (a) 3. (b) 4 (c) 5 (d) 6 Ans. (d) 67. In a group of travelling in a bus, 6 persons can speak Tamil, 15 can speak Hindi and 6 can speak Gujrati. In that group none can speak any other language. If 2 persons in the group can speak two languages and one person can speak all the three languages, then how many persons are there in the group? (a) 21 (b) 22 (c) 23 (d) 24 Ans. (d) 68. A boat which has a speed of 5 km/hr in still water crosses a river of width 1 km along the shortest possible path in 15 minutes. The velocity of the river water in km/hr is (a) 1 (b) 3 (c) 4 (d) v41 Ans. (a) 69. When three coins are tossed together the probability that all coins have the same face up, is (a) 1/3 (b) 1/6 (c) 1/8 (d) 1/12 Ans. (c) Directions (Q 68-Q 72):,Study the following arrangement carefully and answer the questions given below: H93P$KE%4FR I U@WG2MI5BQZ6 ©*N&8VJ 70. If all the symbols and numbers are dropped from the above arrangement, which of the following will be the fourteenth from the right end? (a) M (b) K (c) W (d) E Ans. (d) 71. What should come in place of the question mark (? ) in the following series based on the above arrangement? _PK% RUW M5Q ? (a)  ©N8. (b)  ©N15 (c) 15*15 (d) 6*8 Ans. (a) 72. How many such numbers are there in the above arrangement each of which is immediately preceded by a letter and immediately followed by a symbol? (a) None (b) One (c) Two (d) Three Ans. (b) 73. Which of the following is the seventh-to the left of the twentieth from the left end of the above arrangement? (a) U (b)S (c)M (d)N Ans. (a) 74. How many such consonants are there in the above arrangement each of which is immediately followed by a number but not immediately preceded by a number? (a) None (b) One (c) Two (d) More than three Ans. (d) 75. Left pan of faulty weighs 100gram more than is right pan. A shopkeeper keeps the weight measure in the left pan while buying goods but keeps it in the right pan while selling his goods. He uses only 1kg weight measure. If he sells his goods at the listed cost price, What is his gain? (a) 200/11% (b) 100/11% (c) 1000/9% (d) 200/9% Ans. (a) 76. Societies have been increasing in complexity from folk to industrial. Under this circumstances, according to you social control is more likely to be invested in – (a) family (b) school (c) state (d) religious structures Ans. (c). Instructions (Q 77-Q 86): Read the following passage carefully and answer the questions given below it. â€Å"The big difference between the ideas of Aristotle and those of Galileo and Newton is that Aristotle believed in a preferred state of rest, which any body would take up if it were not driven by some force or impulse. In particular, he thought that the earth was at rest. But it follows from Newton’s laws that there is no unique standard of rest. One could equally well say that body A was at rest and body B was moving at constant speed with respect to body A, or that body B was at rest and body A was moving. For example, if one sets aside for a moment the rotation of the earth and its orbit round the sun, one could say that the earth was at rest and that a train on it was travelling north at ninety miles per hour or that the train was at rest and the earth was moving south at ninety miles per hour. If one carried out experiments with moving bodies on the train, all Newton’s laws would still hold. For instance, playing Ping-pong on the train, one would find that the ball obeyed Newton’s laws just like a ball on a table by the track. So there is no way to tell whether it is the train or the earth that is moving. The lack of an absolute standard of rest meant that one could not determine whether two events that took place at different times occurred in the same position in space. For example, suppose our Ping-Pong ball on the train bounces straight up and down. Hitting the table twice on the same spot one second apart. To someone on the track, the two bounces would seem to take place about forty meters apart, because the train wood have traveled that far down the track between the bounces. The nonexistence of absolute rest therefore meant that one could not give an event an absolute position in space, as Aristotle had believed. The position of events and the distance between them would be different far a person of the train and one on he track, and there would be no reason to prefer one person’s position to the other’s. Newton was very worried by this lack of absolute position, or absolute space, as it was called, because it did not accord with his idea of an absolute God. In fact, he refused to accept lack of absolute space, even though it was implied by his laws. He was severely criticized for this irrational belief by many people, most notably by Bishop Berkeley, a philosopher who believed that all material objects and space and time are an illusion. When the famous Dr. Johnson was told of Brekeley’s opinion, he cried, â€Å"I refute it thus! † and stubbed his toe on a large stone. Both Aristotle and Newton believed in absolute time. That is, they believed that one could unambiguously measure the interval of time between two events, and that this time would be the same whoever measured it, provided they used a good clock. Time was completely separate from and independent of space. This is what most people would take to be the commonsense view. However, we have had to change our ideas about space and time. Although our apparently commonsense nations work well when dealing with things like apples, or planets that travels comparatively slowly, they don’t work at all things moving at or near the speed of light. † 77. Consider the following statements: 1. Newton is a firm beliver of both absolute time and a preferred state of rest 2. Aristotle believer in absolute time 3. Newton believes in absolute time 4. Galileo believes in a preferred state of rest (a) 1 Only (b) 1 & 2 (c) 2 & 3 (d) 1, 2, 3 & 4 Ans. (c) 78. According to the author, what is the need of space? 1. To set an absolute standard of rest 2. To determine rest and motion. 3. To determiner whether two events taking place at the same time takes place in the same space also 4. To determine the defference between time and space (a) 1 & 2 (b) 1, 2 & 3 (c) 3 & 4 (d) 1, 2, 3 & 4 Ans. (c) 79. According to Aristotle- (a) Position of events and distances between them an different (b) Space is nonexistent (c) All nonexistent bodies have absolute rest (d) None of the above Ans. (a) 80. From the passage what can we infer? (a) There is no rest (b) There is rest (c) There is absolute rest (d) There is no absolute rest Ans. (d) 81. What seems contradictory in Newton’s laws? (a) Newton’s concept of Absolute God. (b) Concept of Absolute space (c) Concept of rest (d) None of these Ans. (b) 82. Who discards material objects and space and time? (a) Newton (b) Aristotle (c) Barkeley (d) Galileo Ans. (c) 83. Consider the following statements according to the information provided in paragraph three? (a) On Barkeleys opinion, Dr. Johnson had no remarks (b) Dr. Johnson criticized Barkeley vehemently (c) Dr. Johnson accepted Barkeley’s view (d) Dr. Johnson was indifferent Ans. (b) 84. â€Å"The interval of time between two events can be measured unambiguously. †-this implies- (a) Absolute space (b) Absolute time (c) Both Absolute time and absolute space (d). Neither absolute time non absolute space Ans. (b) 85. The term â€Å"unambiguous† means? (a) Clean and proper (b) Perfect (c) Confusing or not difined (d) Well difined Ans. (c) 86. What does the author openion in the passage? (a) Time is completely separated and independent from space (b) Time and space and interdependent (c) Time is dependent on space and not vice-versa (d) Space is dependment on time and vice-versa Ans. (a) 87. A sum of money invested for a certain number of years at 8% p. a. simple interest grows to Rs. 180. The same sum of money invested for the same number of years at 4% p. a.simple interest grows to Rs. 120 only. For how many years was the sum invested? (a) 25 years (b) 40 years (c) 33 years and 4 months (d) Cannot be determined Ans. (a) 88. How long will it take for a sum of money to grow from Rs. 1250 to Rs. 10,000, if it is invested at 12. 5% p. a simple interest? (a) 8 years (b) 64 years (c) 72 years (d) 56 years Ans. (d) 89. Rs. 5887 is divided between Shyam and Ram, such that Shyamaâ‚ ¬Ã¢â€ž ¢s share at the end of 9 years is equal to Ramaâ‚ ¬Ã¢â€ž ¢s share at the end of 11 years, compounded annually at the rate of 5%. Find the share of Shyam. (a) 2088 (b) 2000 (c) 3087 (d) None of these Ans. (c) 90. An equilateral triangular plate is to be cut in to n number of identical small equilateral triangular plates. Which of the following can be possible value of n? (a) 196 (b) 216 (c) 256 (d) 296 Ans. (c) 91. Find the area of the sector covered by the hour hand after it has moved through 3 hours and the length of the hour hand is 7cm. (a) 1. 77 sq. cm (b) 2. 38. 5 sq. cm (c) 3. 35 sq. cm (d) 4. 70 sq. cm Ans. (b) 92. Left pan of faulty weighs 100gram more than is right pan. A shopkeeper keeps the weight measure in the left pan while buying goods but keeps it in the right pan while selling his goods. He uses only 1kg weight measure. If he sells his goods at the listed cost price, What is his gain? (a) 200/11% (b) 100/11% (c) 1000/9% (d) 200/9% Ans. (a) 93. Societies have been increasing in complexity from folk to industrial. Under this circumstances, according to you social control is more likely to be invested in – (a) family (b) school (c) state (d) religious structures Ans. (c) 94. Each interior angle of a regular polygon is 120 degrees greater than each exterior angle. How many sides are there in the polygon? (a) 6 (b) 8 (c) 12 (d) 3 Ans. (c) 95. In the following question, the student’s clinical judgement is assessed: A 28 year old woman with one child has taken anti-thyroid drugs for 6 months for thyrotoxicosis. She has a friend who has been successfully treated with radioiodine. She finds she frequently forgets to take her drugs and wants to stop them to have radio-iodine treatment. 1. She should be told that because of her age radio-iodine is best avoided. 2. The problems associated with radio-iodine should be discussed with her. 3. Surgery as a possible alternative should be discussed with her. 4. She should be advised that some form of further treatment is required. 5. You should find out more about her friend’s treatment. (a) 1 only (b) 2, 3 & 4 (c) 1 & 5 (d) 1, 2 & 3 Ans. (b) 96. In a certain store, the profit is 320% of the cost. If the cost increases by 25% but the selling price remains constant, approximately what percentage of the selling price is the profit? (a) 30% (b) 70% (c) 100% (d) 250% Ans. (b) Directions for the following questions from Question No 97 to Question No 100: The following passage in this section is followed by questions based on the content of the reading passage. Read the passage carefully and chose the best answer to each question below. â€Å"But man is not destined to vanish. He can be killed, but he cannot be destroyed, because his soul is deathless and his spirit is irrepressible. Therefore, though the situation seems dark in the context of the confrontation between the superpowers, the silver lining is provided by amazing phenomenon that the very nations which have spent incalculable resources and energy for the production of deadly weapons are desperately trying to find out how they might never be used. They threaten each other, intimidate each other and go to the brink, but before the total hour arrives they withdraw from the brink. † 97. What is the synonym of the word, confrontation? (a) Being face to face (b) Involving in a clash (c) Fair relationship (d) None of the above Ans: (a) 98. What is the crux of the passage? (a) Man’s soul and spirit can not be destroyed by superpowers. (b) Man’s soul and spirit are immortal. (c)Man’s safety is assured by the delicate balance of power in terms of nuclear weapons. (d) Human society will survive despite the serious threat of total annihilation. Ans : (d) 99. The phrase ‘Go to the brink’ in the passage means – (a) Retreating from extreme danger. (b) Declare war on each other. (c) Advancing to the stage of war but not engaging in it. (d) Commit suicide. Ans : (c) 100. What is the author’s opinion? (a) Nations in possession of huge stockpiles of lethal weapons are trying hard to avoid actual conflict. (b) Huge stockpiles of destructive weapons have so far saved mankind from a catastrophe. (c) Mankind is heading towards complete destruction. —

Domestic Violence And Its Effects On Society - 2241 Words

Domestic violence, a highly prevalent, almost authorized, legally penalized, almost always hidden heinous crime, has been a matter of concern in many countries. More so in India, as every 2 in 5 women face domestic violence in India and about once every five minutes an incident of domestic violence is reported in India, under its legal definition of cruelty by husband or his relatives. Although it is gender neutral, domestic violence is usually perpetrated against women and hence it becomes essential to understand the male perspective of the same. What exactly is domestic violence? World health organization defines a synonymous term intimate partner violence as Intimate partner violence refers to behaviour by an intimate partner or ex-partner that causes physical, sexual or psychological harm, including physical aggression, sexual coercion, psychological abuse and controlling behaviours. In India, domestic violence is mainly seen as a crime against women and the prevention and puni shment of domestic violence is contained in the Protection of Women from Domestic Violence Act, 2005. Section 3 of the act defines domestic violence as any act or omission that harms or injures or endangers the health, safety, life, or well-being, whether mental or physical, of the aggrieved person or tends to do so and includes causing physical abuse, sexual abuse, verbal and emotional abuse and economic abuse; or harasses, harms, injures or endangers the aggrieved person with a view to coerceShow MoreRelatedDomestic Violence And Its Effects On Society1745 Words   |  7 Pages Domestic Violence in Literature Domestic violence entails transgressions that tend to exhibit regular occurrence worldwide. Domestic violence is substantially attributable to the psychological, physical, mental, and sexual forms of suffering or anguish. 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How to Use Functions and Procedures in Delphi

Have you ever found yourself writing the same code over and over to perform some common task within event handlers? Yes! Its time for you to learn about programs within a program. Lets call those mini-programs subroutines. Intro to subroutines Subroutines are an important part of any programming language, and ​Delphi is no exception. In Delphi, there are generally two types of subroutines: a ​function and a procedure. The usual difference between a function and a procedure is that a function can return a value, and a procedure generally will not do so. A function is normally called as a part of an expression. Take a look at the following examples: procedure SayHello(const sWhat:string) ; begin ShowMessage(Hello sWhat) ; end; function YearsOld(const BirthYear:integer): integer; var Year, Month, Day : Word; begin DecodeDate(Date, Year, Month, Day) ; Result : Year - BirthYear; end; Once subroutines have been defined, we can call them one or more times: procedure TForm1.Button1Click(Sender: TObject) ; begin SayHello(Delphi User) ; end; procedure TForm1.Button2Click(Sender: TObject) ; begin SayHello(Zarko Gajic) ; ShowMessage(You are IntToStr(YearsOld(1973)) years old!) ; end; Functions and Procedures As we can see, both functions and procedures act like mini-programs. In particular, they can have their own type, constants and variable declarations inside them. Take a closer look at a (miscellaneous) SomeCalc function: function SomeCalc (const sStr: string; const iYear, iMonth: integer; var iDay:integer): boolean; begin ... end; Every procedure or function begins with a header that identifies the procedure or function and lists the parameters the routine uses if any. The parameters are listed in parentheses. Each parameter has an identifying name and usually has a type. A semicolon separates parameters in a parameter list from one another. sStr, iYear, and iMonth are called constant parameters. Constant parameters cannot be changed by the function (or procedure). The iDay is passed as a var parameter, and we can make changes to it, inside the subroutine. Functions, since they return values, must have a return type declared at the end of the header. The return value of a function is given by the (final) assignment to its name. Since every function implicitly has a local variable Result of the same type as the functions return value, assigning to Result has the same effect as assigning to the name of the function. Positioning and Calling Subroutines Subroutines are always placed in the implementation section of the unit. Such subroutines can be called (used) by an event handler or subroutine in the same unit that is defined after it. Note: the uses clause of a unit tells you which units it can call. If we want a specific subroutine in a Unit1 to be usable by the event handlers or subroutines in another unit (say Unit2), we have to: Add Unit1 to the uses clause of Unit2Place a copy of the header of the subroutine in the interface section of the Unit1. This means that subroutines whose headers are given in the interface section are global in scope. When we call a function (or a procedure) inside its own unit, we use its name with whatever parameters are needed. On another hand, if we call a global subroutine (defined in some other unit, e.g. MyUnit) we use the name of the unit followed by a period. ... //SayHello procedure is defined inside this unit SayHello(Delphi User) ; //YearsOld function is defined inside MyUnit unit Dummy : MyUnit.YearsOld(1973) ; ... Note: functions or procedures can have their own subroutines​ embedded inside them. An embedded subroutine is local to the container subroutine and cannot be used by other parts of the program. Something like: procedure TForm1.Button1Click(Sender: TObject) ; function IsSmall(const sStr:string):boolean; begin //IsSmall returns True if sStr is in lowercase, False otherwise Result:LowerCase(sStr)sStr; end; begin //IsSmall can only be uses inside Button1 OnClick event if IsSmall(Edit1.Text) then ShowMessage(All small caps in Edit1.Text) else ShowMessage(Not all small caps in Edit1.Text) ; end;