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Intensive Blood Glucose Control and Vascular Outcomes in Patients with Type 2 Diabetes. Metformin: an old medication of new fashion: evolving new molecular mechanisms and clinical implications in polycystic ovary syndrome. Before waiver consideration, aviators should have complete resolution of symptoms and be taking no medications incompatible with flying. Complete history of the problem to include all consultants seen, medications used and procedures, if any. Colonic diverticular disease is quite common, accounting for 300,000 hospitalizations and 1. Diverticular disease has less than a 5% incidence in persons less than age 40 but the incidence increases rapidly thereafter, with about 60% of the general population developing the condition by age 80. The true incidence is difficult to ascertain as most patients are asymtomatic4, 5, but recent studies suggest an increasing prevalence of diverticular disease, especially in patients under the age of 50. In an accompanying editorial, it was noted that there have been large studies demonstrating an association between low fiber intake and diverticular complications, whereas the cited study focused on asymptomatic diverticulosis. The diagnostic approach to patients with abdominal pain and altered bowel function generally includes colonoscopy in order to assess for significant mucosal pathology. Traditional medical treatment includes a high-fiber diet consisting of wheat bran and/or commercial bulking agents, but research findings bring these recommendations into question. A systematic review of 11 studies that investigated probiotics as a treatment for symptomatic diverticulosis found that the quality of studies and strength of evidence lacked sufficient weight to recommend for or against their use. Patients with diverticulitis often present with left lower quadrant pain and tenderness, nausea, fever, and leukocytosis. Treatment is based on the overall health of the patient and the severity of the disease. Stable, uncomplicated patients who tolerate liquids can be treated as outpatients with oral antibiotics. The success rate of such conservative treatment in patients with acute uncomplicated diverticulitis is greater than 90 percent. Those with complications such as perforation, abscess formation, fistulization, sepsis or partial obstruction should be hospitalized for medical and/or surgical treatment. Physicians have historically stressed the avoidance of nuts, seeds and popcorn to reduce the risk of recurrent diverticulitis. Some recent studies have refuted this notion as a cause of diverticular complications, and these dietary restrictions should no longer be routinely recommended. This was based on studies showing younger patients with more virulent disease and a greater overall risk of recurrence due to a longer lifespan. Such patients should be counseled on the risks and benefits of accepting or declining elective segmental-colectomy for diverticular disease as several studies have shown that up to 25% of patients experienced persistent symptoms after elective surgery. In left-sided colonic diverticulosis, this bleeding is often seen as bright red blood per rectum. Slower rates of bleeding or bleeding from the more proximal colon may result in darker blood or clots in the stool. The mechanism for diverticular hemorrhage is poorly understood, but the bleeding is arterial in nature and is thought to relate to endothelial damage. Bleeding stops spontaneously in up to 90% of cases but can recur during the index hospitalization, or post discharge in up to 38% of patients. Current treatment has shifted from angiography and urgent surgery to mechanical colonoscopic interventions. Acute diverticular hemorrhage or perforation are capable of causing in-flight physical incapacitation, but altered bowel habits, abdominal distention, episodic pain, nausea, and flatulence related to symptomatic diverticulosis could be a distraction and affect crew availability. An aviator with acute diverticulitis would be ill-suited to fly due to fever and pain. Inflammatory and Anatomic Diseases of the Intestine, Peritoneum, Mesentery, and Omentum. Selective non-antibiotic treatment in sigmoid diverticulitis: is it time to change the traditional approach?

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Until more is known, this suggests that some caution is appropriate on concurrent use. See also willow, page 399, for more information on herbs that possess antiplatelet properties. Thisoda P, Rangkadilok N, Pholphana N, Worasuttayangkurn L, Ruchirawat S, Satayavivad J. Inhibitory effect of Andrographis paniculata extract and its active diterpenoids on platelet aggregation. Antithrombotic effects of Andrographis paniculata nees in preventing myocardial infarction. Constituents Aniseed fruit contains 2 to 6% of a volatile oil composed mostly of trans-anethole (80 to 95%), with smaller amounts of estragole (methyl chavicol), -caryophyllene and anise ketone (p-methoxyphenylacetone). Natural coumarins present include scopoletin, umbelliferone, umbelliprenine and bergapten, and there are numerous flavonoids present, including quercetin, apigenin and luteolin. Aniseed appears to have some oestrogenic effects, but the clinical relevance of this is unclear. For information on the interactions of individual flavonoids present in aniseed, see under flavonoids, page 186. Although aniseed contains natural coumarins, the quantity of these constituents is not established, and therefore the propensity of aniseed to interact with other drugs because of their presence is unclear. Consider natural coumarins, page 297, for further discussion of the interactions of natural coumarin-containing herbs. Effects of the naturally occurring alkenylbenzenes eugenol and trans-anethole on drug-metabolizing enzymes in the rat liver. Use and indications Aniseed dried fruit, or oil distilled from the fruit, are used mainly for their antispasmodic, carminative and parasiticide effects. Pharmacokinetics Studies in rats suggested that trans-anethole did not alter 33 34 Aniseed oestrogenic. Importance and management these experimental studies provide limited evidence of the possible oestrogenic activity of aniseed. Estrogenic activity of isolated compounds and essential oils of Pimpinella species from Turkey, evaluated using a recombinant yeast screen. Aniseed + Oestrogens the interaction between aniseed and oestrogens is based on experimental evidence only. Experimental evidence In a yeast oestrogen screen assay, the fruit oil from aniseed was Aristolochia Aristolochia species (Aristolochiaceae) A Synonym(s) and related species the nomenclature of these and related plants has given rise to confusion with other, non-toxic plants. This has been exacerbated by the fact that different Chinese names have been used for each species. Birthwort has been used as a collective name for the Aristolochia species, but it has also been used for one of the species, Aristolochia clematitis L. The Chinese name Mu Tong has been used to refer to some of the Aristolochia species. Aristolochia fangchi has been referred to by the Chinese names Fang Chi, Fang Ji, Guang Fang Ji. Constituents All species contain a range of toxic aristolochic acids and aristolactams. Use and indications Aristolochic acids and aristolactams are nephrotoxic, carcinogenic and cytotoxic. Numerous deaths have resulted from aristolochic acid nephropathy and associated urothelial cancer, caused by ingestion of aristolochia both medicinally and from contamination of food. All plants of the family Aristolochiaceae are banned in Europe and elsewhere, and should be avoided. Constituents the main constituents of the bark are triterpenoid saponins including arjunic acid, arjunolic acid, arjungenin and arjunglycosides, and high levels of flavonoids, such as arjunone, arjunolone, luteolin and quercetin. Polyphenols, particularly gallic acid, ellagic acid and oligomeric proanthocyanidins, are also present. Interactions overview Arjuna appears to have some effects on cardiovascular function, which may lead to interactions with conventional drugs used for similar indications. Arjuna may also affect thyroid function, which could alter the control of both hyperand hypothyroidism.


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People with diabetes may be at increased risk for the bacteremic form of pneumococcal infection and have been reported to have a high risk of nosocomial bacteremia, with a mortality rate as high as 50% (18). In autoimmune diseases, the immune system fails to maintain self-tolerance to specific peptides within target organs. Cancer Compared with the general population, people with type 1 or type 2 diabetes have higher rates of hepatitis B. This may be due to contact with infected blood or through improper equipment use (glucose monitoring devices or infected needles). The association may result from shared risk factors between type 2 diabetes and cancer (older age, obesity, and physical inactivity) but may also be due to diabetes-related factors (29), such as underlying disease physiology or diabetes treatments, although evidence for these links is scarce. In a long-term study of older patients with type 2 diabetes, individuals with one or more recorded episode of severe hypoglycemia had a stepwise increase in risk of dementia (37). Therefore, fear of cognitive decline should not be a barrier to statin use in individuals with diabetes and a high risk for cardiovascular disease. Fatty Liver Disease Diabetes is associated with the development of nonalcoholic chronic liver disease and with hepatocellular carcinoma (42). Postpancreatitis diabetes may include either newonset disease or previously unrecognized diabetes (48). Both patient and disease factors should be carefully considered when deciding the indications and timing of this surgery. Up to half of patients with diabetes may have impaired exocrine pancreas function (45). Age-specific hip fracture risk is significantly increased in people with both type 1 (relative risk 6. Fracture prevention strategies for people with diabetes are the same as for the general population and include vitamin D supplementation. Current evidence suggests that periodontal disease adversely affects diabetes outcomes, although evidence for treatment benefits remains controversial (23). Psychosocial/Emotional Disorders In men with diabetes who have symptoms or signs of hypogonadism such as decreased sexual desire (libido) or activity, or erectile dysfunction, consider screening with a morning serum testosterone level. B Mean levels of testosterone are lower in men with diabetes compared with agematched men without diabetes, but obesity is a major confounder (66,67). Testosterone replacement in men with symptomatic hypogonadism may have benefits including improved sexual function, well being, muscle mass and strength, and bone density. Obstructive Sleep Apnea Prevalence of clinically significant psychopathology diagnoses are considerably more common in people with diabetes than in those without the disease (76). Providers should consider an assessment of symptoms of depression, anxiety, and disordered eating, and of cognitive capacities using patient-appropriate standardized/ validated tools at the initial visit, at periodic intervals, and when there is a change in disease, treatment, or life circumstance. Diabetes distress is addressed in Section 4 "Lifestyle Management," as this state is very common and distinct from the psychological disorders discussed below (77). The prevalence of obstructive sleep apnea in the population with type 2 diabetes may be as high as 23%, and the prevalence of any sleep disordered breathing may be as high as 58% (70,71). Periodontal Disease c Consider screening for anxiety in people exhibiting anxiety or worries regarding diabetes complications, insulin injections or infusion, taking medications, and/or hypoglycemia that interfere with self-management behaviors and those who express fear, dread, or irrational thoughts and/or show anxiety symptoms such as avoidance behaviors, excessive repetitive behaviors, or social withdrawal. Common diabetesspecific concerns include fears related to hypoglycemia (80,81), not meeting blood glucose targets (78), and insulin injections or infusion (82). Onset of complications presents another critical point when anxiety can occur (83). Fear of hypoglycemia and hypoglycemia unawareness often co-occur, and interventions aimed at treating one often benefit both (86). Fear of hypoglycemia may explain avoidance of behaviors associated with lowering glucose such as increasing insulin doses or frequency of monitoring. Depression Recommendations c c c Periodontal disease is more severe, and may be more prevalent, in patients with Anxiety symptoms and diagnosable disorders. Providers should consider annual screening of all patients with diabetes, especially those with a self-reported history of depression, for depressive symptoms with age-appropriate depression screening measures, recognizing that further evaluation will be necessary for individuals who have a positive screen. Regardless of diabetes type, women have significantly higher rates of depression than men (93). Routine monitoring with patientappropriate validated measures can help to identify if referral is warranted.

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They may also occur as accompanying symptoms in other psychiatric conditions including but not limited to bipolar disorder. Bipolar Disorders are considered on a continuum as part of a spectrum of disorders where there are significant alternations in mood. Generally, only one episode of manic or hypomanic behavior is necessary to make the diagnosis. Even if the bipolar disorder does not have accompanying symptoms that reach the level of psychosis, the disorder can be so disruptive of judgment and functioning (especially mania) as to pose a significant risk to aviation safety. Although they may be rare in occurrence, severe anxiety problems, especially anxiety and phobias associated with some aspect of flying, are considered significant. Organic mental disorders that cause a cognitive defect, even if the applicant is not psychotic, are considered disqualifying whether they are due to trauma, toxic exposure, or arteriosclerotic or other degenerative changes. When the Examiner reaches Item 48 in the course of the examination of an applicant, it is recommended that the Examiner take a moment to review and determine if key procedures have Guide for Aviation Medical Examiners been performed in conjunction with examinations made under other items, and to determine the relevance of any positive or abnormal findings. Two or more units (more than 500 ml) this includes Power Red (double red cell donation) C. Include frequency, severity and location of bleeding sites Submit a current status report and all pertinent medical reports. Example: Thrombocytopenia due to chemotherapy, malignancy, autoimmune disorders, or alcohol use. Applicants for first- or secondclass must provide this information annually; applicants for third-class must provide the information with each required exam. If treatment was short-term counseling for Gender Dysphoria only, note in Block 60. Surgery: If surgery has been performed within the last one year, a status report from the surgeon or current treating physician showing full release, off any sedation or pain medication, and any surgical complications. No other treatment is needed (do not include support group or support group counseling). Any evidence of cognitive dysfunction or is a formal neuropsychological evaluation indicated? Applicants for firstor second-class must provide this information annually; applicants for third-class must provide the information with each required exam. If surgery has been performed, the airman is off all pain medication(s), has made a full recovery, and has been released by the surgeon. The airman is back to full, unrestricted activities and no new treatment is recommended at this time. The Examiner may wish to counsel applicants concerning piloting aircraft during the third trimester. Hearing Conversational Voice Test at 6 Feet Pass Fail Record Audiometric Speech Discrimination Score Below I. The applicant must demonstrate an ability to hear an average conversational voice in a quiet room, using both ears, at a distance of 6 feet from the Examiner, with the back turned to the Examiner. If an applicant fails the conversational voice test, the Examiner may administer pure tone audiometric testing of unaided hearing acuity according to the following table of worst acceptable thresholds, using the calibration standards of the American National Standards Institute, 1969: 5 0 0 H z 3 5 3 5 1 0 0 0 H z 3 0 5 0 2 0 0 0 H z 3 0 5 0 3 0 0 0 H z 4 0 6 0 Frequency (Hz) Better ear (Db) Poorer ear (Db) If the applicant fails an audiometric test and the conversational voice test had not been administered, the conversational voice test should be performed to determine if the standard applicable to that test can be met. If an applicant is unable to pass either the conversational voice test or the pure tone audiometric test, then an audiometric speech discrimination test should be administered. A passing score is at least 70 percent obtained in one ear at an intensity of no greater than 65 Db. For all classes of certification, the applicant must demonstrate hearing of an average conversational voice in a quiet room, using both ears, at 6 feet, with the back turned to the Examiner. If the applicant is unable to hear a normal conversational voice then "fail" should be marked and one of the following tests may be administered. For all classes of certification, the applicant may be examined by pure tone audiometry as an alternative to conversational voice testing or upon failing the conversational voice test. If the applicant fails the pure tone audiometric test and has not been tested by conversational voice, that test may be administered. Upon failing both conversational voice and pure tone audiometric test, an audiometric speech discrimination test should be administered (usually by an otologist or audiologist).

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Unlike differentiated thyroid cancer, anaplastic carcinoma responds poorly to treatment. Palliative or debulking therapies are done in conjunction with radiation and chemotherapy with limited success. Treatment of medullary thyroid carcinoma is also surgical, but more aggressive cervical dissections are indicated. Post-surgery, patients are monitored by following the levels of calcitonin as a tumor marker. Those with near normal post-operative calcitonin values can be followed clinically, but those with levels >100 pg/ml of calcitonin should be evaluated for other resectable lesions. A positive scan or persistent elevations of thyroglobulin can indicate residual carcinoma or recurrence. Recombinant thyrotropin stimulation is much better tolerated by the patients since the hypothyroid symptoms are avoided and can now be used for treatment as well as follow-up. Most recurrences are localized to the thyroid bed or cervical lymph nodes and occur within 5 years of diagnosis. In some cases, it may represent residual normal thyroid tissue and be completely benign; however, this conclusion should only be made after adequate evaluation. Surgery, repeat radioactive iodine treatment or observation (in some cases) is done as clinically indicated. This low level of disease burden does not impact shortterm risk and does not cause incapacitation; therefore, unless there are other indications for grounding, aviators may remain on flying status during the evaluations. Differentiated thyroid cancer poses little aeromedical risk unless there are distant metastases. Fortunately, only 10% of patients develop distant metastases over their life-time, and the majority are seen in the lungs. Even if residual disease is documented, the short-term risks are unchanged unless distant metastases are apparent. Post-surgical complications include hypothyroidism, and the small risk of damage to the recurrent laryngeal nerves and parathyroid glands due to local invasion, or surgical damage. Hypothyroidism is easily treated with thyroxine replacement; however, there may be times when replacement is deliberately withheld as part of treatment with the goal of inducing hypothyroidism for radioactive iodine scanning or treatment. The mild thyrotoxicosis slightly increases the risk of atrial fibrillation, but is not associated with sudden incapacitation and would not limit aviation duties. In patients with thyroid cancer, surgery can lead to damage to the parathyroid glands resulting in permanent hypoparathyroidism causing hypocalcemia which can lead to tingling and muscle cramping or potentially life-threatening tetany. It is easily treated with calcium and sometimes requires calcitriol, but most patients never have a problem as long as they are taking their pills. Symptoms of hypocalcemia are easily recognizable and reversible with calcium, long before a life-threatening event like tetany would occur. Likewise any lesion of the recurrent laryngeal nerve, whether iatrogenic or part of the natural disease process, would have further potential aeromedical implications. Unilateral involvement would likely result in increased vocal hoarseness which may affect the aviators ability to effectively communicate; particularly in an environment with significant levels of ambient noise. Unilateral damage should be considered on a case-by-case basis, but bilateral damage is not a waiverable condition. Medullary thyroid cancer can be an indolent process depending on the extent of the initial tumor. Thus, the same post-operative considerations exist as for the differentiated thyroid carcinomas. Since local invasion is the primary risk; aeromedical concerns center on local damage or risks for future invasion or recurrence. Waiver can be 902 Distribution A: Approved for public release; distribution is unlimited. Waiver can also be considered for those with only biochemical evidence of persistent disease with negative imaging, on a case by case basis, to include the small number with stable persistent disease with positive imaging, but not bad enough to require surgery. Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer. American Thyroid Association Guidelines for Management of Patients with Anaplastic Thyroid Cancer. Thyroid cancer incidence patterns in the United States by histologic type, 1992-2006. Rising thyroid cancer incidence in the United States by demographic and tumor characteristics, 1980-2005.

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If a granular material is ingested and the patient has symptomatic mucosal burns, refer patient to a surgeon or gastroenterologist for consideration of endoscopy and management. If vomiting has not occurred, give patient water or milk for dilution, not to exceed approximately 15 mL/kg in a child or 120-240 mL in an adult. Administration of acids is contraindicated, because of the risk or increasing generation of chlorine gas. If a high concentration solution is in contact with the eyes, wash eyes profusely and examine corneas carefully. If exposure to vapors or chlorine or chloramine gas has occurred, move patient immediately to fresh air. If symptoms occur or persist, oxygenation should be assessed and oxygen administered as needed. Povidine-iodine is described as an iodophor, which is a complex of iodine and polyvinylpyrrolidone, a solubilizing agent. Though highly concentrated iodine solutions or iodine salts are corrosive to the gastrointestinal tract,31 solutions of povidone-iodine have little caustic potential. All symptomatic poisonings reported have occurred either after repeated exposure to burned skin or following irrigation of wounds, joints or serosal surfaces, such as the mediastinum. Use osmotic agents or diuretics in symptomatic poisonings, since iodine clearance is apparently enhanced by procedures that enhance chloride excretion. Treat seizures with anticonvulsants, as outlined in Chapter 3, General Principles. These included phenylmercuric acetate, phenylmercuric nitrate, nitromersol, thimerosol, mercurochrome and mercurobutol. The toxicity and treatment of exposure to these compounds is described in detail in Chapter 16, Fungicides under the subsection Organomercury Compounds. Cresol and thymol are alkyl derivatives of phenol, while hexachlorophene and triclosan are chlorinated phenols. One survey found that triclosan or a similar agent, triclocarban, was found in 45% of liquid and bar soaps available in consumer outlets. Ingestion of concentrated forms causes severe corrosive injury to the mouth and upper gastrointestinal tract. Hypotension, myocardial failure, pulmonary edema, neurological changes may also occur. These compounds are well absorbed from the gastrointestinal tract and are also significantly absorbed from the skin and by inhalation. Do not attempt gastrointestinal decontamination because of the corrosive nature of these compounds. If a corrosive injury has occurred with burns to the mouth, or if there is a clear history of gastrointestinal exposure, consider endoscopy and consult a gastroenterologist or surgeon for diagnosis and management. If a high concentration solution is in contact with the eyes, wash eyes with profuse amounts of water and follow with a careful exam of the corneas. Given the corrosive nature of the substance, referral to an ophthalmologist should be considered. Provide respiratory and circulatory support in accordance with sound medical management. If severe systemic symptoms persist, the patient should be treated in an intensive care unit, if possible. Toxicology of Hexachlorophene Hexachlorophene is well absorbed via the oral and dermal routes. Dermal exposures have led to severe toxicity and death in neonates, due to application to damaged skin or repeated or high-concentration skin exposures. It is not significantly caustic, however, and exposure does not result in the severe caustic injuries seen with other phenolic chemicals. Lethargy is an early manifestation, followed by muscular weakness, muscular fasciculation, irritability, cerebral edema and paralysis, leading to coma and death. In severe poisonings, cardiovascular symptoms, including hypotension and bradycardia have been noted. Although this compound is quite toxic systemically and enhanced clearance methods would appear beneficial, there is no evidence to support efficacy of hemodialysis, peritoneal dialysis, hemoperfusion or exchange transfusion.

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I recall an inexperienced colleague treating "slow ventricular tachycardia" with lidocaine, and the patient developed asystole. It would be hard to exercise with a heart rate that slow, but syncope is uncommon. If complete block occurs farther down, within the septum and beyond the division of the two bundle branches (see Fig 1. These deeper pacers have a much slower intrinsic rate, occasionally as slow as 10 to 20 beats/min. From this outline of general principles, you begin to see that the level of block determines prognosis, and identification of this level is critical. Because of delayed conduction between atria and ventricles, contraction of the ventricle is much later than usual. During this delay, atrial contraction finishes, and the mitral and tricuspid valves drift toward the closed position. When the ventricles finally contract the valves do not have as far to travel, so the closure sound is softer. I find it easier to remember without the Mobitz designations, instead thinking anatomically of where the conduction system block occurs. I repeat this because it is important (it will be the key to answering a Board question). This "H spike" can be measured with an electrode that is near it, using an electrode catheter positioned in the lower right atrium next to the tricuspid valve. Block in the node causes A-H interval prolongation, and block below the node-below the proximal His-causes H-V interval prolongation. Infranodal block identified by a long H-V interval is an indication for a pacemaker. Complete heart block is just one of the conditions where this occurs, and you will encounter other examples in Chapter 2. Furthermore, the takeover pacemaker is relatively high in the conduction system and has an intrinsic rate ranging from 35 to 45 beats/min. The rate would probably increase with catecholamine infusion or administration of atropine. When I ask students about the cause of the arrhythmia the usual response is coronary artery disease (the default response when in doubt). But infranodal heart block in the elderly is rarely a complication of ischemic heart disease. In this age group, the cause is fibrotic degeneration of the infranodal nerves ("frayed wires"). The idioventricular pacing rate does not increase following treatment with atropine or catecholamines. The patient usually has a history of slow pulse, as the takeover pacemaker in the upper His system has a rate in the mid-40s. It helps to remember how the location of block determines the severity of the arrhythmia and prognosis. Permanent pacemaker therapy is rarely needed, although temporary pacing is indicated for symptomatic bradycardia. An anterior infarction large enough to cause infranodal block is usually huge, spontaneous recovery from the heart block is rare, and the prognosis is terrible. The P wave that is blocked may be buried in the T wave of the preceding complex, making it hard to see. The concept is one that is often misunderstood, but is actually quite simple (Fig 1. The reentrant "focus" is an island of cardiac tissue that is protected, or insulated, from surrounding tissue. Current enters one end of the focus and exits the other (conduction is unidirectional). Within the focus, conduction is much slower than conduction through the surrounding tissue. Thus, the current exiting the focus finds the surrounding tissue vulnerable, ready to be stimulated, and that is just what happens: a premature beat is generated.

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Improving Care and Promoting Health in Populations Diabetes and Population Health Tailoring Treatment for Social Context S86 9. Microvascular Complications and Foot Care Diabetic Kidney Disease Diabetic Retinopathy Neuropathy Foot Care S13 2. Children and Adolescents Type 1 Diabetes Type 2 Diabetes Transition From Pediatric to Adult Care S38 4. Lifestyle Management Diabetes Self-Management Education and Support Nutrition Therapy Physical Activity Smoking Cessation: Tobacco and e-Cigarettes Psychosocial Issues S137 13. Prevention or Delay of Type 2 Diabetes Lifestyle Interventions Pharmacologic Interventions Prevention of Cardiovascular Disease Diabetes Self-management Education and Support S144 14. Diabetes Care in the Hospital Hospital Care Delivery Standards Glycemic Targets in Hospitalized Patients Bedside Blood Glucose Monitoring Antihyperglycemic Agents in Hospitalized Patients Hypoglycemia Medical Nutrition Therapy in the Hospital Self-management in the Hospital Standards for Special Situations Transition From the Acute Care Setting Preventing Admissions and Readmissions S55 6. Glycemic Targets Assessment of Glycemic Control A1C Testing A1C Goals Hypoglycemia Intercurrent Illness S65 7. Obesity Management for the Treatment of Type 2 Diabetes Assessment Diet, Physical Activity, and Behavioral Therapy Pharmacotherapy Metabolic Surgery S152 15. Diabetes Advocacy Advocacy Position Statements Professional Practice Committee, American College of Cardiology-Designated Representatives, and American Diabetes Association Staff Disclosures S73 8. A table linking the changes in recommendations to new evidence can be reviewed at professional. The need for an expert consensus report arises when clinicians, scientists, regulators, and/or policy makers desire guidance and/or clarity on a medical or scientific issue related to diabetes for which the evidence is contradictory, emerging, or incomplete. The scientific review may provide a scientific rationale for clinical practice recommendations in the Standards of Care. A 2015 analysis of the evidence cited in the Standards of Care found steady improvement in quality over the previous 10 years, with the 2014 Standards of Care for the first time having the majority of bulleted recommendations supported by A- or B-level evidence (4). Recommendations with lower levels of evidence may be equally important but are not as well supported. Although levels of evidence for several recommendations have been updated, these changes are not addressed below as the clinical recommendations have remained the same. Improving Care and Promoting Health in Populations A new recommendation was added about using reliable data metrics to assess and improve the quality of diabetes care and reduce costs. The recommendation for testing for prediabetes and type 2 diabetes in children and adolescents was changed, suggesting testing for youth who are overweight or obese and have one or more additional risk factors (Table 2. A clarification was added that, while generally not recommended, community screening may be considered in specific situations where an adequate referral system for positive tests is established. Additional detail was added regarding current research on antihyperglycemic treatment in people with posttransplantation diabetes mellitus. Text was added about the importance of language choice in patient-centered communication. Pancreatitis was added to the section on comorbidities, including a new recommendation about the consideration of islet autotransplantation to prevent postsurgical diabetes in patients with medically refractory chronic pancreatitis who require total pancreatectomy. A recommendation was added to consider checking serum testosterone in men with diabetes and signs and symptoms of hypogonadism. The recommendation regarding the use of metformin in the prevention of prediabetes was reworded to better reflect the data from the Diabetes Prevention Program. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. A new recommendation was added that all hypertensive patients with diabetes should monitor their blood pressure at home to help identify masked or white coat hypertension, as well as to improve medication-taking behavior. A new section was added describing the mixed evidence on the use of hyperbaric oxygen therapy in people with diabetic foot ulcers. The recommended risk-based timing of celiac disease screenings for youth and adolescents with type 1 diabetes was defined. Based on new evidence, a recommendation was added for women with type 1 and type 2 diabetes to take low-dose aspirin starting at the end of the first trimester to lower the risk of preeclampsia.

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Exceptions to this classic picture, as described further below, do occur, with prominent demyelinization in extrapontine sites associated with movement disorders or delirium in the absence of quadriplegia. Over time the flaccidity resolves, to be replaced by spasticity with hyperreflexia. Exceptions to this classic picture occur when demyelinization occurs in extrapontine locations. Thus, one may see delirium alone (without quadriplegia) (Hadfield and Kubal 1996; Karp and Laureno 1993) or a movement disorder such as dystonia (Maraganore et al. In those who survive, recovery may begin within a week or two of the syndrome reaching its peak intensity, with maximum recovery taking up to a year; enduring deficits may include a variable degree of quadriparesis or dementia (Menger and Jorg 1999). In cases characterized by a movement disorder, symptoms may either resolve over many months or be chronic, or, in the case of dystonia, may actually gradually worsen. Although such a scenario is most likely in chronic alcoholics given intravenous fluids (Lampl and Yazdi 2002), other groups at risk include the recipients of liver transplants (Estol et al. Although this mechanism appears operative for the vast majority of cases, other mechanisms may also be found. For example, central pontine myelinolysis has been noted in severe burn patients who were not hyponatremic but who had developed a severe hyperosmolar state (McKee et al. Pathologically, in classic cases one finds symmetric demyelinization within the basis pontis (Adams et al. This is most prominent within the central portion of the pons and spreads outward but does not involve the periphery of the pons where a rim of intact white matter survives. This demyelinization may at times extend to the pontine tegmentum and occasionally also into the mesencephalon, but the medulla is generally spared. Extrapontine myelinolysis, as noted, may also occur, and has been noted in the centrum semiovale, internal capsule, striatum, thalamus, subthalamic nucleus, and the lateral geniculate body (Wright et al. In pathologic material, the most common pattern is myelinolysis confined to the pons, followed by myelinolysis involving both the pons and extrapontine sites; the least common pattern consists of myelinolysis solely in extrapontine sites (Gocht and Colmant 1987). Differential diagnosis Classic cases must be distinguished from stroke secondary to infarction in the area of distribution of the basilar artery. In cases characterized by delirium alone, the clue, of course, would be the history of rapid correction of hyponatremia 2 or 3 days earlier. Etiology As noted earlier, the classic precipitant for central pontine myelinolysis is the overly rapid correction of a chronic hyponatremia (Brunner et al. In cases of chronic hyponatremia, intracellular osmolarity gradually falls to maintain an osmotic balance with the hypo-osmolar extracellular fluid. However, when the hyponatremia is rapidly corrected, an osmotic gradient does occur, with a substantial fluid shift from the intracellular to extracellular compartments. Oligodendrocytes appear particularly affected by this osmotic shift, and these cells, in particular those located within the pons, become damaged or die, leading Treatment As there is no specific treatment for acute central pontine myelinolysis, prevention is essential. It must be borne in mind that, when chronic, hyponatremia is often relatively well-tolerated and indeed some patients may be asymptomatic. In chronic cases that come to autopsy, an excess of protoplasmic astrocytes has been found. Certain disorders, such as polyarteritis nodosa and systemic lupus erythematosus, may not only cause renal failure but also directly affect the central nervous system. Another example is malignant hypertension, which may cause a concurrent hypertensive encephalopathy and renal failure. Renal failure is also associated with subdural hematoma (Fraser and Arieff 1988), hypocalcemia, and hypomagnesemia, each of which may also cause delirium. Finally, attention must be paid to toxicity from drugs excreted primarily via the kidneys.

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Although several organizations have identified policy recommendations to close gaps in access to pain management services,287,288 coverage barriers persist. Although the literature exploring the effectiveness of interventions for patients with painful conditions and comorbid psychiatric concerns is limited, research suggests that regular monitoring and early referral and intervention can improve pain and psychiatric outcomes and prevent negative opioid-related outcomes. Conduct regular reevaluation and assessment, with a treatment plan and established goals, to achieve optimal patient outcomes. For improved functionality, activities of daily living, and quality of life, clinicians are encouraged to consider and prioritize, when clinically indicated, nonpharmacologic approaches to pain management. My right arm was ripped open down to my hand and I had some shrapnel in both of my legs and my left arm. Overall, I had 26 surgeries over 3 1/2 years in the hospital, where I started receiving alternative therapy. After I got out of being an inpatient, I told myself I was going to get off of all my meds and I did that. I watched too many fellow service members, comrades, turn into zombies just being pumped full of medications. If my foot stays down for a long period of time, it gets swollen, and I have limited feeling from my left knee down to my foot. I went through a form of visual and audio therapy and somehow that triggered those nerves to kick back in. I think a combination of acupuncture and digital medicine is, in a sense, the way of the future. The use of complementary and integrative health approaches for pain has grown within care settings across the United States over the past decades. As with other treatment modalities, complementary and integrative health approaches can be used as stand-alone interventions or as part of a multidisciplinary approach, as clinically indicated and based on patient status. Examples of complementary and integrative health approaches to pain include acupuncture, hands-on manipulative techniques. These therapies can be provided or overseen by licensed professionals and trained instructors. The use of complementary and integrative health approaches should be communicated to the pain management team. Overall, most complementary and integrative health approaches can provide improved relief, when clinically indicated, when used alone or in combination with conventional therapies such as medications, behavioral therapies, and interventional treatments, although more research to develop evidence-informed treatment guidelines is needed. The following paragraphs briefly describe complementary and integrative health approaches, which can be considered singularly or as part of a multimodal approach to the management of chronic and acute pain, depending on the patient and his or her medical conditions. This list is not inclusive or exhaustive but instead provides examples of common complementary and integrative health approaches. It involves manipulating a system of meridians where "life energy" flows by inserting needles into identified acupuncture points. The therapeutic value of acupuncture in the treatment of various pain conditions, including osteoarthritis; migraine; and low-back, neck, and knee pain has growing evidence in the form of systematic reviews and meta-analyses. Massage and manipulative therapies, including osteopathic and chiropractic treatments, are commonly used for pain management. Such interventions may be clinically effective for short-term relief323,324 and are best accomplished in consultation with the primary care and pain management teams. Studies on massage have considered various types, including Swedish, Thai, and myofascial release, but these studies do not provide adequate details of the type of massage provided. Systematic reviews note that the few studies looking at the effect of massage on pain use rigorous methods and large sample sizes. Mindfulness enables an attentional stance of removed observation and is characterized by concentrating on the present moment with openness, curiosity, and acceptance. Yoga has become popular in Western cultures as a form of mind and body exercise that incorporates meditation and chants. Modern tai chi has become popular for core physical strengthening through its use of slow movements and meditation. It has demonstrated long-term benefit in patients with chronic pain caused by osteoarthritis and other musculoskeletal pain conditions. People living with pain may use religious or spiritual forms of coping, such as prayer and meditation, to help manage their pain. Growing evidence indicates that spiritual practices and resources are beneficial for people with pain.


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