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Note about trial measure: this measure is intended for internal quality improvement use to measure prevalence of patients with type 2 diabetes whose glucose and cardiovascular factors are poorly controlled. Percentage of newly diagnosed patients who are advised about lifestyle modifcation and nutrition therapy within one year of diagnosis. Percentage of patients with blood pressure most recent measurement less than 140/90 mmHg. Number patients with most recent blood pressure measurement less than 140/90 mmHg. Notes this is an outcome measure, and improvement is noted as an increase in the rate. This measure should be calculated as both an individual components met and a composite (all components met at the same time) measure. Notes this is a process measure, and improvement is noted as a decrease in the rate. Notes this is a process measure, and improvement is noted as an increase in the rate. It is expected that users of these tools will establish the proper copyright prior to his/her use. Professionals Wide variety of information on diabetes as well as recent publications; series of jour nals for both consumers and health profes sionals; community resources. The Food and Nutrition the Food and Nutrition Information Patients and. Families International Diabetes International Diabetes Center: Patients and. National Institutes of National Institutes of Health: this user Health Care. Glycaemic separation and risk factor control in the veterans affairs diabetes trial: an interim report. Identifying adults at high risk for diabetes and cardiovascular disease using hemoglobin A1c national health and nutrition examination survey 2005 2006. Clinical effect of metformin in children and adolescents with type 2 diabetes mellitus: a systematic review and meta-analysis. Long term effects of the angiotensive converting enzyme inhibitor captopril on metabolic control in non-insulin dependent diabetes mellitus. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Blood pressure targets in subjects with type 2 diabetes mellitus/impaired fasting glucose: observations from traditional and bayesian random-effects meta analyses of randomized trials. Diabetic renal disease recommendations: screening and management of microalbuminuria in patients with diabetes mellitus: recommendations to the Scientifc Advisory Board of the National Kidney Foundation from an ad hoc committee of the Council on Diabetes Mellitus of the National Kidney Foundation. Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus: a meta-analysis of controlled clinical trials. One-year comparison of a high-monosaturated fat diet with a high-carbohydrate diet in type 2 diabetes. A comparison of the infuence of a high-fat diet enriched in monounsaturated fatty acids and conventional diet on weight loss and metabolic parameters in obese non-diabetic and type 2 diabetic patients. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. A randomized controlled trial of resistance exercise training to improve glycemic control in older adults with type 2 diabetes. The relative benefts of endurance and strength training on the metabolic factors and muscle function of people with type 2 diabetes mellitus. Effcacy of cholesterol-lowering therapy in 18, 686 people with diabetes in 14 randomised trials of statins: a meta-analysis. Effects of aerobic and resistance training on hemoglobin A1c levels in patients with type 2 diabetes: a randomized controlled trial. Effects of gastric bypass surgery in patients with type 2 diabetes and only mild obesity. Prevalence of hypertension and obesity in patients with type 2 diabetes mellitus in observational studies: a systematic literature review. Group based training for self-management strategies in people with type 2 diabetes mellitus. Case-matched outcomes in bariatric surgery for treatment of type 2 diabetes in the morbidly obese patient. High-intensity resistance training improves glycemic control in older patients with type 2 diabetes. A low carbohydrate Mediterranean diet improves cardiovascular risk factors and diabetes control among overweight patients with type 2 diabetes mellitus: a 1-year prospective randomized intervention study. Effects of a Mediterranean-style diet on the need for antihy perglycemic drug therapy in patients with newly diagnosed type 2 diabetes: a randomized trial. Effect of intensive blood pressure control with valsartan on urinary albumin excretion in normotensive patients with type 2 diabetes. Effects of outcome on in-hospital transition from intravenous insulin infu sion to subcutaneous therapy. Multifactoral intervention and cardiovascular disease in patients with type 2 diabetes. American college of endocrinology position statement on inpatient diabetes and metabolic control. Meta-analysis of randomized educational and behavioral interventions in type 2 diabetes. Trends in the prevalence and ratio of diagnosed to undiagnosed diabetes according to obesity levels in the U. Type 2 diabetes mellitus, physical activity, exercise self-effcacy, and body satisfaction: an application of the transtheoretical model in older adults. Renal disease in the managed care setting: selection and monitoring of outcome criteria. Targeting intensive glycaemic control versus targeting conventional glycaemic for type 2 diabetes mellitus. Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the diabetes surgery study randomized clinical trial. International expert committee report on the role of A1c assay in the diagnosis of diabetes. Clinical effcacy of orlistat therapy in overweight and obese patients with insulin-treated type 2 diabetes. Prevalence and risk of diabetic retinopathy when age at diagnosis is 30 or more years. New management concepts for timely diagnosis of diabetic retinopathy treatable by photocoagulation. Utility of glycated hemoglobin in diagnosing type 2 diabetes mellitus: a community-based study. Motivational interviewing and problem solving treatment to reduce type 2 diabetes and cardiovascular disease risk in real life: a randomized controlled trial. Renoprotective effect of the angiotensin-receptor antago nist irbesartan in patients with nephropathy due to type 2 diabetes. A population study on the association between leisure time physical activity and self-rated health among diabetics in Taiwan. The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing diabetes prevention study: a 20-year follow-up study. Medication utilization and annual health care costs in patients with type 2 diabetes mellitus before and after bariatric surgery.

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She has continuing psychotic symptomatology, interspersed with 136 Psychiatry episodes of a major mood disorder. Notably, she has never had the mood symptoms without the psychotic symptoms, ruling out major depression with psychosis as the diagnosis. Delusional disorder is not accompanied by decline in functions or significant affective symptoms. Individuals with schizoid personality disorder do not experience psychotic symptoms. Bipolar disorder is differentiated from schizoaffective disorder by the absence of periods of psychosis accompanied by prominent affective symp toms. Patients with the persecutory subtype of delusion are convinced they are being harassed or harmed by others. Those with the jealous type are often ver bally and physically abusive to those involved in the delusion (the wife in this case). Somatic type delusions cause the sufferer to believe that they are afflicted with some physical disorder, and this belief is fixed (unlike hypochondriasis, in which the sufferer can be relieved of the belief that something is wrong, if only temporarily). Grandiose delusions have the patient believing that there is something special about him/her, such as God giving special messages. Unspecified delusions are those reserved for presentations which cannot be characterized by the previous types. One example is Capgras syndrome, which is a delusion in which the patient believes that familiar people have been replaced by imposters. Injectable depot medications such as haloperidol decanoate and fluphenazine decanoate are effective in decreasing the rate of relapse in patients who are not compliant with oral medication. The episode lasts at least 1 day and less than 1 month and is followed by full spontaneous remission. For the woman in the question, the psychotic episode was clearly precipitated by the death of her children. Schizophreniform disorder is differentiated from brief psychotic disorder by temporal factors (in schizophreniform disorder, symptoms are required to last more than 1 month) and lack of association with a stressor. Posttraumatic stress disorder has a more chronic course and is characterized by affective, dissociative, and behavioral symptoms. Other adverse social factors are missing, and the family history is one of affective disorder, not schizophrenia. In addition, precipitating fac tors are usually present, and the onset of the disease is rapid, not insidious, in patients with good-outcome schizophrenia. Some investigators believe that prominent visual hallucina tions and a relative absence of thought disorder are more characteristic of amphetamine psychosis, but other investigators believe the symptoms are indistinguishable. Other signs that point to a medical cause could be other mental status signs such as speech, movement or gait disorders, problems with 138 Psychiatry alertness, memory, concentration, or orientation, and a concurrent sub stance abuse history or medical problem. She postulated that faulty mothering leads to anxiety and distrust of others, causing people who develop schizophrenia to withdraw from interpersonal exchanges. This theory has been discredited by recent research that supports the notion that schizophrenia is a brain disorder caused by the convergence of multiple environmental and genetic factors. However, subsequent study of the effect of expressed emotion (family members expressive of hostility and overly controlling) do show that this behavior leads to an increase in relapse rates. As many as 20% of patients with a diagnosis of schizophrenia drink excessive amounts of water. At least 4% of these patients suffer from chronic hyponatremia and recurrent acute water intoxication. Medications that cause excessive water retention, such as lithium and carbamazepine, can aggravate the sympto matology. Guidelines state that such a patient should be discontinued from antipsychotic medication, although a gradual reduction in the med ication first, along with more frequent visits to the psychiatrist during this time, should be implemented to minimize the risk of relapse. In addition, it is recommended that the patient and family be encouraged to develop early intervention strategies prior to medication discontinuation, should a relapse occur. The delusions may be reversed if their cause is treatable (eg, a delusion occurring secondary to a medication intoxication). The delusions are Schizophrenia and Other Psychotic Disorders Answers 139 usually responsive to antipsychotic medications. Symptoms of anxiety and depression may also occur, but not with such overwhelming frequency as is seen with delusions. It is quite likely that if he is admitted, he will be found to have some secondary-gain reason for wanting to be in the hospi tal (eg, to avoid the legal system). It is unlikely at his age that he would sud denly become ill with schizophreniform disorder, schizophrenia, or schizoaffective disorder. The rather simplistic description of hallucinations in an otherwise clear sensorium and the absence of a disordered thought process also arise the suspicion of malingering. Although the patient does have marijuana in his system, its presence serves to highlight that this patient is being less than truthful rather than suggesting a substance induced psychosis, since it is unlikely marijuana alone would cause such symptoms. Capgras syndrome (delusion of doubles) is a fixed belief that familiar persons have been replaced by identical imposters who behave exactly like the original person. Cotard syndrome is the false perception of having lost everything, including money, status, strength, health, and inter nal organs. Folie a deux is a shared psychotic disorder in which one person develops psychotic symptoms similar to the ones a long-term partner has been experiencing. A 40-year-old woman with a history of chaotic interpersonal rela tionships enters psychoanalytic psychotherapy. She alternates between periods in which she idealizes the therapist and the progress of the therapy and periods of unrelenting anger when she is convinced that the therapist is unhelpful and that the therapeutic work is worthless. Which of the fol lowing defense mechanisms is being used by the patient in this scenario The patient is asked to relive the stressful events while scanning relaxation materials. The patient concentrates on slowing his blink rate while processing the stress ful event. The patient follows a small light projected on the ceiling to achieve a deeply relaxed state. His physician explains the use of the medication and tells the patient that he will need to be seen at frequent intervals until his glucose levels come under good control. A 45-year-old woman comes to the psychiatrist requesting help in coping with her life. The patient states both of her parents have recently been diagnosed with cancer and her husband has just instituted divorce proceedings. She states she feels overwhelmed and anxious, with bouts of crying and panic attacks. A 32-year-old woman presented to the psychiatric emergency room after a suicide attempt in which she swallowed a bottle of aspirin. On the inpatient unit it was noted that she was stealing needles and injecting feces under her skin to cause infections. Which of the following guidelines is most useful for therapy with patients with this disorder Appoint a psychiatrist as the primary gatekeeper for all medical and psychiatric treatments. Use invasive diagnostic procedures early to get a quick diagnosis of any pre senting physical signs or symptoms. What is the most common reason that psychotherapy for personality disorders is so difficult to carry out successfully A patient in psychodynamic therapy has been coming late to the last few sessions and complaining in the sessions that he has nothing to talk about.

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Additional details regarding the patient focus group methods and findings can be found in Appendix D. Using shared decision-making, consider all treatment options and develop a treatment plan based on the balance of risks, benefits, and patient-specific goals, values, and preferences. A structured algorithm accompanies the guideline to provide an overview of the recommendations in the context of the flow of patient care and clinician decision making and to assist with training providers. The algorithm may be used to help facilitate translation of guideline recommendations into effective practice. Clinicians must be skilled at presenting their patients with understandable and actionable information regarding both individual treatments and levels and locations of care. Use of an empathetic and non-judgmental (versus a confrontational) approach facilitates discussions sensitive to gender, culture, and ethnic differences. The information that patients are given about treatment and care should be culturally appropriate and also available to people with limited literacy skills. It should also be accessible to people with additional needs such as physical, sensory, or learning disabilities. Family involvement should be considered if appropriate, especially in elderly patients. Lastly, they should involve the patient in prioritizing problems to be addressed and in setting specific goals regardless of the selected setting or level of care. The algorithm serves as a tool to prompt providers to consider key decision points in the course of an episode of care. The use of the algorithm format as a way to represent patient management was chosen based on the understanding that such a format may promote more efficient diagnostic and therapeutic decision making and has the potential to change patterns of resource use. Standardized symbols are used to display each step in the algorithm and arrows connect the numbered boxes indicating the order in which the steps should be followed. We recommend shared decision-making to enhance patient knowledge Strong for Reviewed, and satisfaction. We recommend that all patients with diabetes should be offered ongoing Strong for Reviewed, individualized diabetes self-management education via various modalities New-replaced tailored to their preferences, learning needs and abilities based on available resources. We suggest offering one or more types of bidirectional telehealth Weak for Reviewed, interventions (typically health communication via computer, telephone or New-replaced other electronic means) involving licensed independent practitioners to patients selected by their primary care provider as an adjunct to usual patient care. We recommend setting an HbA1c target range based on absolute risk Strong for Reviewed, reduction of significant microvascular complications, life expectancy, New-added patient preferences and social determinants of health. We recommend assessing patient characteristics such as race, ethnicity, Strong for Reviewed, chronic kidney disease, and non-glycemic factors. We recommend an individualized target range for HbA1c taking into Strong for Reviewed, account individual preferences, presence or absence of microvascular New-replaced complications, and presence or severity of comorbid conditions (See Table 2). We recommend that in patients with type 2 diabetes, a range of HbA1c Strong for Reviewed, 7. We suggest that providers be aware that HbA1c variability is a risk factor Weak for Reviewed, for microvascular and macrovascular outcomes. We recommend a nutrition intervention strategy reducing percent of energy Strong for Reviewed, from carbohydrate to 14-45% per day and/or foods with lower glycemic New-added index in patients with type 2 diabetes who do not choose the Mediterranean diet. We recommend against targeting blood glucose levels <110 mg/dL for all Strong Reviewed, hospitalized patients with type 2 diabetes receiving insulin. We recommend insulin be adjusted to maintain a blood glucose level Strong for Reviewed, between 110 and 180 mg/dL for patients with type 2 diabetes in critically Amended ill patients or those with acute myocardial infarction. We recommend against the use of split mixed insulin regimen for all Strong Reviewed, hospitalized patients with type 2 diabetes. We suggest a regimen including basal insulin and short-acting meal time or Weak for Reviewed, basal insulin and correction insulin for non-critically ill hospitalized New-added patients with type 2 diabetes. We suggest providing medication education and diabetes survival skills to Weak for Reviewed, patients before hospital discharge. We recommend performing a comprehensive foot risk assessment Strong for Not Reviewed, annually. We recommend referring patients with limb-threatening conditions to the Strong for Not Reviewed, appropriate level of care for evaluation and treatment. We suggest screening for retinopathy at least every other year (biennial Weak for Not Reviewed, screening) for patients who have had no retinopathy on all previous Amended examinations. We recommend that all females with pre-existing diabetes or personal Strong for Not Reviewed, history of diabetes and who are of reproductive potential be provided Amended contraceptive options education and education on the benefit of optimizing their glycemic control prior to attempting to conceive. We recommend that all females with pre-existing diabetes or personal Strong for Not Reviewed, history of diabetes who are planning pregnancy be educated about the Amended safest options of diabetes management during the pregnancy and referred to a maternal fetal medicine provider (when available) before, or as early as possible, once pregnancy is confirmed. We recommend shared decision-making to enhance patient knowledge and satisfaction. Key principles include the patient/family readiness, provision of benefits and harms of all options in understandable tools, and incorporation of preferences. This should include, at a minimum, diagnosis, difficulties in management, and times of transition or development of complications. Studies indicate there may be other approaches that use health coaching and motivational interviewing approaches to promote medication compliance/adherence and follow through. When a provider uses motivational interviewing skills it may increase the dialogue between provider and patient thus developing a trust level more rapidly and more effectively. Sharing healthcare decisions requires a healthcare system which supports the process, and patients, providers, and healthcare team members who are encouraged to share decisions. We recommend that all patients with diabetes should be offered ongoing individualized diabetes self-management education via various modalities tailored to their preferences, learning needs and abilities based on available resources. The process requires ongoing interactive information-sharing between the diabetes team and the patient. A strong message from the focus group was that clinicians need to account for the specific circumstances. The reviewed literature addressed various modes of delivery and varied in the content of educational materials and time allotted for the intervention (varied from 1 to >20 hours), as well as the specific population subgroups that were studied. Other options may include community-based programs, web-based education, or phone applications. A key suggestion made by the focus group participants was to create a formal support system for patients with diabetes such as web-based, online chats, or other types of support groups and diabetes education classes to enhance involvement and support. Online learning allows the learner to engage in topics of personal interest and reinforce concepts by repeating online classes during asynchronous, flexible times. It also allows learners, family members, and co-workers the ability to acquire needed information without taking time away from their work schedule. Ideally, this should be conducted at each visit and addressed accordingly using education resources available to the medical treatment facility. Evidence shows that self-management training is effective, but most reviews called for further research by way of well-designed and long-term studies. Computer-based diabetes self-management interventions have limited evidence supporting their use and more research is needed for design, delivery and effectiveness. We suggest offering one or more types of bidirectional telehealth interventions (typically health communication via computer, telephone or other electronic means) involving licensed independent practitioners to patients selected by their primary care provider as an adjunct to usual patient care. However, patients were returned to conventional care after six months and the effect was not sustainable at the 12-month mark. Patients in the telehealth intervention had statistically significant sustained reductions of HbA1c over five years of follow-up, but the difference in HbA1c reduction was not clinically significant (telemedicine: mean 7. There was no significant difference in changes in HbA1c from baseline to six months of follow-up.

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Design Population Stichprobe Intervention Kompa Primar Wichtigste Schwachen/ Evidenz Ref rator Endpunkt Ergebnisse Bias Niveau Liste 3 Observat. Design Population Stichprobe Intervention Kompa Primar Wichtigste Schwachen/ Evidenz-Niveau Ref rator Endpunkt Ergebnisse Bias Liste 13 Observat. Design Population Stichprobe Intervention Kompa Primar Wichtigste Schwachen/ Evidenz Ref rator Endpunkt Ergebnisse Bias Niveau Liste 16 Review, nicht bewertet n. Abhan gigkeit von Geschlecht, maternaler und paternaler Groe 24 Review Allgemeinbildend, nicht bewertet n. Interventions to Try to Prevent Preterm Birth in Women With a History of Conization: A Systematic Review and Meta-analyses. Magnetic resonance imaging for prenatal estimation of birthweight in pregnancy: review of available data, techniques, and future perspectives. Interventions during pregnancy to prevent preterm birth: an overview of Cochrane systematic reviews. Prognosis of the co-twin following spontaneous single intrauterine fetal death in twin pregnancies: a systematic review and meta-analysis. Maternal clinical predictors of preterm birth in twin pregnancies: A systematic review involving 2, 930, 958 twin pregnancies. Umbilical cord milking in preterm neonates requiring resuscitation: A randomized controlled trial. Perinatal outcomes in intrahepatic cholestasis of pregnancy with monochorionic diamniotic twin pregnancy. Pravastatin and-L-arginine combination improves umbilical artery blood flow and neonatal outcomes in dichorionic twin pregnancies through an nitric oxide-dependent vasorelaxant effect. Diagnosis of a neonatal ophthalmic discharge, Ophthalmia neonatorum, in the molecular age: investigation for a correct therapy. Pessary for prevention of preterm birth in twin pregnancy with short cervix: 3-year follow-up study. Occupational, Environmental, and Lifestyle Factors and their Contribution to Preterm Birth An Overview. Preterm premature rupture of membranes is a collateral effect of improvement in perinatal outcomes following fetoscopic coagulation of chorionic vessels for twin-twin transfusion syndrome: a retrospective observational study of 1092 cases. Intrauterine insemination versus intracervical insemination in donor sperm treatment. Accuracy of fetal fibronectin for assessing preterm birth risk in asymptomatic pregnant women: a systematic review and meta-analysis. Pregnancy after bariatric surgery: Maternal and fetal outcomes of 39 pregnancies and a literature review. Obstetric complications after frozen versus fresh embryo transfer in women with polycystic ovary syndrome: results from a randomized trial. Short cervix in twin pregnancies: current state of knowledge and the proposed scheme of treatment. Cervical pessaries for the prevention of preterm birth: a systematic review and meta-analysis. What is the safest mode of delivery for extremely preterm cephalic/non-cephalic twin pairs Early warning system hypertension thresholds to predict adverse outcomes in pre-eclampsia: A prospective cohort study. Prenatal administration of progestogens for preventing spontaneous preterm birth in women with a multiple pregnancy. The frequency and clinical significance of intra-amniotic inflammation in twin pregnancies with preterm labor and intact membranes. Delayed-interval delivery in twin pregnancies: report of three cases and literature review. Association of histological chorioamnionitis and magnesium sulfate treatment in singleton and dichorionic twin pregnancies with preterm premature rupture of membranes: preliminary observations. Pessary or Progesterone to Prevent Preterm delivery in women with short cervical length: the Quadruple P randomised controlled trial. Effect of vaginal progesterone in tocolytic therapy during preterm labor in twin pregnancies: Secondary analysis of a placebo-controlled randomized trial. Principles of first trimester screening in the age of non-invasive prenatal diagnosis: screening for other major defects and pregnancy complications. Induction of Lactation in the Biological Mother After Gestational Surrogacy of Twins: A Novel Approach and Review of Literature. Selective intrauterine growth restriction in monochorionic diamniotic twin pregnancies. Observational study of associations between gestational weight gain and perinatal outcomes in dichorionic twin pregnancies. Re-Thinking Elective Single Embryo Transfer: Increased Risk of Monochorionic Twinning A Systematic Review. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Bed rest with and without hospitalisation in multiple pregnancy for improving perinatal outcomes. Triplet Pregnancy in a Diabetic Mother With Kidney Transplant: Case Report and Review of the Literature. Delayed-interval delivery can save the second twin: evidence from a systematic review. Preterm birth prevention in twin pregnancies with progesterone, pessary, or cerclage: a systematic review and meta-analysis. Worldwide prevalence of adverse pregnancy outcomes associated with in vitro fertilization/intracytoplasmic sperm injection among multiple births: a systematic review and meta-analysis based on cohort studies. Population-based study on antenatal corticosteroid treatment in preterm small for gestational age and non-small for gestational age twin infants. Riskin-Mashiah S, Reichman B, Bader D, Kugelman A, Boyko V, Lerner-Geva L, Riskin A; Israel Neonatal Network. Prenatal diagnosis and management of vasa previa in twin pregnancies: a case series and systematic review. Use of antenatal corticosteroids in special circumstances: a comprehensive review. Obstetric outcome of vanishing twins syndrome: a systematic review and meta-analysis. Vaginal progesterone decreases preterm birth and neonatal morbidity and mortality in women with a twin gestation and a short cervix: an updated meta-analysis of individual patient data. The effect of induction method in twin pregnancies: a secondary analysis for the twin birth study. Body stalk anomaly in a monochorionic-diamniotic twin pregnancy case report and review of the literature. Multiple exposures to environmental pollutants and oxidative stress: Is there a sex specific risk of developmental complications for fetuses Case of twin pregnancy complicated by idiopathic thrombocytopenic purpura treated with intravenous immunoglobulin: Review of the literature. Central pontine myelinolysis during pregnancy: Pathogenesis, diagnosis and management. Cervical pessary for preventing preterm birth in twin pregnancies with short cervical length: a systematic review and meta-analysis. Neonatal morbidities and need for intervention in twins and singletons born at 34-35 weeks of gestation. Observational study of the safety of buprenorphine+naloxone in pregnancy in a rural and remote population. Expectant management versus multifetal pregnancy reduction in higher order multiple pregnancies containing a monochorionic pair and a review of the literature. Twin pregnancies after assisted reproductive technologies: the role of maternal age on pregnancy outcome. Pregnancy in spinal cord-injured women, a cohort study of 37 pregnancies in 25 women.

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I almost evident from several successful engineers gave up, until I was struck by an idea that with disabilities, disability is no barrier to 01 PersPective 37 Digital technology is creating opportunities for children with disabilities, such as this blind boy in Kuala Lumpur, Malaysia, who uses text-to-speech software to take part in classes. Thus, there is a dire becomes important to intensify our efforts in need to encourage and, more importantly, this space. Similarly, several applications and websites of Science in computer science at fail to comply with accessibility standards, Stanford University with a focus on compelling more than 1 billion people with artifcial intelligence. More broadly, what skills and attributes do children need to avoid online risks and maximize opportunities Children should be able to: research supports a narrower defnition for several reasons, including to improve 1. Access and operate in digital the focus of teaching on the subject environments safely and effectively; and to ensure that learning goals are well defned. Communicate safely, responsibly and citizenship, namely: effectively through digital technology; and 1. Kanchev, Expert of the Safer Internet programme at the Applied Research and Even if the defnitions are sometimes fuzzy, the overall goal of teaching digital literacy and Communications Fund in digital citizenship is clear: To equip children with a full portfolio of skills and knowledge that Bulgaria; Sanjay Asthana, allows them to avoid online risks, maximize online opportunities and exercise their full rights School of Journalism, Middle in the digital world. During disease outbreaks, for example, During the dengue outbreak in Pakistan mobile network platforms can provide in 2013, anonymized call data from almost infected individuals and affected households 40 million Telenor Pakistan subscribers were with life-saving information, essential used to predict the spread and timing of commodities and fnancial support. In teachers, improving coordination of humanitarian work, iris scanning has already educational activities during emergencies, been used to repatriate Afghan refugees and disseminating educational information to provide cash transfers to Syrian refugees and supporting the development and in Jordan. Increasingly, these transfers are expanding the reach where violence and unrest have forced administered through mobile money and effciency of cash many children out of school, the government systems, which is expanding their reach transfer programmes. The literature collection and sharing suggests three critical areas where minimum standards should be developed to start in emergencies building a solid framework in the area: There are obvious benefts to using digital Rights, privacy and consent. Common technologies for collecting and sharing data ethical standards are needed to govern the in emergencies. Clear who can generate, access and transmit this guidance is needed on who should share growing food of data. There needs to be a shared understanding Vulnerable groups such as children and of how sharing or using certain types adolescent girls are especially at risk of data can increase the risks faced of violence, abuse and exploitation in by certain groups. However, to fully beneft from the potential of digital In the case of refugees and migrants, technologies in emergencies and other the consequences of data breaches can contexts, the international community become matters of life and death. Unless these gaps in access and skills are identifed and closed, rather than being an equalizer of opportunity, connectivity may deepen inequity, reinforcing intergenerational cycles of deprivation. Disparities in access are particularly striking online or completely unconnected, every in low-income countries: Fewer than child today is growing up in a digital world 5 per cent of children under 15 use the powered by technology and information. For children on the move, it can mean a safer journey, the chance to But digital divides do not merely separate remain in touch with family members and the connected and the unconnected. Those with access education, the types of device they use, to digital technologies and the skills to make family income and the availability of content the best use of them will have the advantage in their own language. Evidence from adult populations Connectivity will a digital space where their language, culture shows that the benefts of digital technology 7 increasingly mean and concerns are notable by their absence. In 2017, Africa was also the region 9 10 much to determine in countries such as India and Tunisia with the highest proportion of non-users refect similar fndings. These disparities in access are particularly Consider mobile technology, which has striking in some low-income countries. The dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The nal status of Jammu and Kashmir has not yet been agreed upon by 0 20 40 60 80 100 the parties. Note: Income classication follows World Bank income classication as of August 2017. The global gap in internet use between men these inequalities in access within countries and women grew from 11 per cent in can reinforce existing inequities for children 2013 to 12 per cent in 2016. But transitioning to an inclusive information society that offers opportunities So how can African children learn the for all is a major global challenge. The internet is steadily breaking Karim Sy and half of the people on the continent now down barriers to accessing knowledge, have a mobile phone contract. Despite the which is no longer the preserve of the Laura Maclet uneven digital and technological landscape, classroom. Yet as technology opens up shown a readiness to embrace mobile access to knowledge, there is a real risk technologies. New apps are appearing that people who cannot use these new all the time, across areas such as agriculture, tools will be left behind.

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Polysomnographic findings in recently drug-free and clinically remitted depressed patients. Sex Ratio: Generalized anxiety disorder is thought to occur two to three times more commonly in women than in men. This finding may contribute to the gen erally higher prevalence of insomnia complaints in women; this prevalence has been found in population studies. Anxiety Disorders (300, 308, 309) Familial Pattern: Generalized anxiety tends to run in families without a clear mode of transmission. Studies of nonclinical populations using the Minnesota Synonyms and Key Words: Generalized anxiety disorder (300. Essential Features: the anxiety disorders are mental disorders that are characterized by symp Complications: Some patients develop sedative or hypnotic abuse, which can toms of anxiety and avoidance behavior. The sleep disturbance associated lead to sleep disorders complicating the original condition. Aside from the gener with anxiety disorders is characterized by a sleep-onset or maintenance al epidemiologic association of reduced sleep time and hypnotic use with insomnia due to excessive anxiety and apprehensive expectation about one increased long-term mortality, there are no specific data on complications of the or more life circumstances. A long-standing generalized anxiety disorder or other anxiety disorder is specific findings of increased sleep latency, decreased sleep efficiency, increased present. The sleep disturbance has followed the time course of the anxiety disorder, changes are often relatively mild. In general, good concordance exists between the without significant long periods of remission. Polysomnographic monitoring demonstrates both of the following: with generalized anxiety has been reported to be similar to that occurring in 1. An increased sleep latency, reduced sleep efficiency, increased frequen patients with psychophysiologic insomnia, although sleep efficiency improves in cy and duration of awakenings patients with psychophysiologic insomnia when sleep is recorded two nights in a 2. Unlike in patients with major depressive disorder, one night of total sleep Note: Specify and code for the type of anxiety disorder and the predominant deprivation does not ameliorate symptoms of anxiety or dysphoria in patients with sleep symptom on axis A. Except for the more extreme cases of objective nocturnal sleep distur insomnia [300. If an anxiety disorder is not the cause of a sleep symptom, bance among these patients, there is usually little or no physiologic sleepiness state and code the anxiety disorder on axis C. Severity Criteria: Differential Diagnosis: the common theme of all of these disturbances is long-standing sleep-onset or maintenance insomnia, which may increase at times Mild: Mild insomnia, as defined on page 23. Anxiety disorders should be contrasted with adjustment sleep disorder, which Severe: Severe insomnia, as defined on page 23. In adjustment sleep disorder, Duration Criteria: there is no premorbid mental history, and sleep has not been impaired before the Acute: Less than 1 month. Such stress might include death of a relative, hos Subacute: More than 1 month and less than 6 months. Although patients with anxiety disorders may ini tially attribute their poor sleep to such stresses, a more detailed history clearly Bibliography: reveals a long-standing sleep and anxiety disturbance preceding that stress. Patients with anxiety disorders have some similarities to those with psychophys Sussman N. As mentioned earlier, polygraphic measures of sleep are similar, and both groups retrospectively report their nocturnal sleep fairly accurate Panic Disorder (300) ly (in contrast to persons with sleep-state misperception). In patients with anxiety disorders, however, the anxiety is generalized, in contradistinction to patients with Synonyms and Key Words: Panic disorder with agoraphobia (300. Conditioned anxiety, however, may be superimposed upon the basic process of sleep disturbance in this, as in many other disorders. Essential Features: Panic disorder is a mental disorder that is characterized by discrete periods Diagnostic Criteria: Anxiety Disorders Associated with Sleep of intense fear or discomfort with several somatic symptoms that occur Disturbance (300, 308, 309) unexpectedly and without organic precipitation. Usually, little or no physiologic sleepiness is seen on the multiple sleep toms also include dizziness, choking, palpitations, trembling, chest pain or dis latency test. Episodes that occur during sleep are associated with a sud den awakening and the onset of typical symptoms. Most patients have daytime panic attacks and symptoms of agoraphobia char Differential Diagnosis: Panic disorder should be differentiated from sleep ter acterized by a fear of being in places or situations from which escape is difficult ror. Sleep-terror episodes commence with a loud scream that occurs out of stage or embarrassing. Common situations include being alone, in a crowd, on a bridge, 3 or stage 4 sleep. Patients with sleep terrors do not have daytime panic episodes or traveling in a bus, train, or car. Similarly, panic attacks are not nightmares, which contain much more mental content and cluster around the early morning hours. Associated Features: the relationship to major depressive disorder is poorly Patients with sleep choking syndrome have a focus of complaint on the inabil understood, although depressive episodes occur in up to 50% of patients with ity to breathe and do not have daytime panic attacks or agoraphobia. It is a chronic condi of daytime anxiety symptoms distinguish apnea from panic disorder. Many clinicians have the impression that the prevalence of Diagnostic Criteria: Panic Disorder Associated with Sleep panic disorder declines in old age, suggesting that there has been some decrease Disturbance (300) in symptomatology. Predisposing Factors: Adults with panic disorder often have histories of child B. The sleep disturbance follows the time course of the above mental distur bance, without significant long periods of remission. Polysomnographic monitoring demonstrates an abrupt awakening with a sensation of panic out of stage 2 or stage 3 sleep. More rarely, the attack is Age of Onset: the average age of onset is the late 20s. The symptoms do not meet the diagnostic criteria for other sleep disorders ly in women than in men. Note: State and code the panic disorder and the predominant sleep symptom on Familial Pattern: Panic disorder tends to run in families without a clear mode axis A. There is an increased concordance among monozygotic twins by enings from sleep [300. If the panic disorder is not the cause of a sleep a ratio of roughly five or six to one. Complications: Panic disorder can be associated with the development of ago Severity Criteria: raphobia, secondary depressive symptoms, and alcoholism. Some patients devel op sedative or hypnotic abuse, which can lead to sleep disorders complicating the Mild: Mild insomnia, as defined on page 23. Polysomnographic Features: As compared to controls, patients with panic Duration Criteria: disorder may have marginally increased sleep latency and decreased sleep effi ciency. Although more rare, the panic attack Subacute: More than 1 month but less than 6 months. There is an increase in movement time, but this move Chronic: 6 months or longer. Sleep 1989; 12: even when the sleepiness is not associated with significant intoxication. A focus on sleep-related panic encephalopathy, can result from chronic alcohol intake. During early alcohol abstinence, delirium tremens can occur and are associat Sussman N. Course: Alcohol abuse often begins in adolescence or early adulthood and Alcoholism (303, 305) reaches a peak cause of hospital admissions in persons in the late 30s or 40s. Sleep quality generally improves, with increas ing deeper sleep and, possibly, some decrease in the amount of dreaming. Some Essential Features: patients never seem to recover to their normal sleep patterns, even after years of abstinence. Alcoholism refers to excessive alcohol intake and applies to both alcohol abuse and dependency. Insomnia or excessive sleepiness is a common fea Predisposing Features: A positive family history for alcoholism is often noted, ture of alcoholism. Alcohol use before bed reduces the amount of wakefulness for the such as insufficient sleep; this potentiation is particularly acute in adolescents and first three to four hours of sleep, but the amount of wakefulness increases during young adults.

Syndromes

  • How much alcohol do you drink?
  • Batteries. The batteries are carried outside your body. They are connected to the pump with a cable that goes into your belly
  • Sexual contact
  • Chronic cough with large amounts of foul-smelling sputum
  • Sydenham chorea (emotional instability, muscle weakness and quick, uncoordinated jerky movements that mainly affect the face, feet, and hands)
  • Rashes may occur anywhere on the body during a bad outbreak.
  • How long has it lasted?
  • Testicular scan (nuclear medicine scan)

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Available the associations between microalbuminuria, coronary atherosclero from. The role of the kidneys in global-report/en/ glucose homeostasis: a new path towards normalizing glycaemia. Pharmacokinetics, pharmacodynamics and clinical use adults with type 2 diabetes: a retrospective observational study. Pharmacokinetic and pharmacodynamic profile of glycaemic control while reducing weight and body fat mass over 2 empagliflozin, a sodium glucose co-transporter 2 inhibitor. Clin years in patients with type 2 diabetes mellitus inadequately con Pharmacokinet. Effects of canagliflozin on and pharmacodynamics of dapagliflozin, a selective inhibitor of body weight and relationship to HbA1c and blood pressure sodium-glucose co-transporter type 2. Safety, tolerability and sodium-glucose cotransporter 2, for the treatment of type 2 dia effects on cardiometabolic risk factors of empagliflozin monother betes mellitus. Pharmacologic approaches to gly dapagliflozin reduces weight and blood pressure but does not cemic treatment: standards of medical care in diabetes 2019. Dapagliflozin lowers over 52 weeks in patients with type 2 diabetes mellitus and chronic blood pressure in hypertensive and non-hypertensive patients with kidney disease. Available from: function decline in patients with type 2 diabetes: a slope analysis. Available from: tion with loop diuretics in diabetic patients with chronic heart. Dapagliflozin and cardiovascular flozin versus glimepiride in patients with type 2 diabetes inade outcomes in type 2 diabetes. Available from: diabetes patients with chronic kidney disease: a randomized clinicaltrials. Effects of empagliflozin effect of sodium-glucose cotransporter 2 inhibition in patients with on the urinary albumin-to-creatinine ratio in patients with type 2 type 1 diabetes mellitus. Empagliflozin reduces cardio invokanar-canagliflozin-being-stopped-early-positive-efficacy vascular events, mortality and renal events in participants with 75. A study to evaluate the effect of dapagli type 2 diabetes after coronary artery bypass graft surgery: flozin with and without saxagliptin on albuminuria, and to 10 J. A study to evaluate the effect of dapagliflozin heart and kidney protection with empagliflozin). Empagliflozin outcome trial in foot care: standards of medical care in diabetes 2019. Diabetes patients with chronic heart failure with preserved ejection fraction Care. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Unfortunately, in many settings the lack of effective policies to create supportive environments for healthy lifestyles and the lack of access to quality health care means that the prevention and treatment of diabetes, particularly for people of modest means, are not being pursued. When diabetes is uncontrolled, it has dire consequences for health and well-being. In addition, diabetes and its complications impact harshly on the fnances of individuals and their families, and the economies of nations. People with diabetes who depend on life-saving insulin pay the ultimate price when access to affordable insulin is lacking. The report makes an important contribution to our understanding of diabetes and its consequences. It advances our understanding of trends in diabetes prevalence, of the contribution of high blood glucose (including diabetes) to premature mortality, and of what action governments are taking to prevent and control diabetes. From the analysis it is clear we need stronger responses not only from different sectors of government, but also from civil society and people with diabetes themselves, and also producers of food and manufacturers of medicines and medical technologies. The report reminds us that effectively addressing diabetes does not just happen: it is the result of collective consensus and public investment in interventions that are affordable, cost-effective and based on the best available science. Please join me in ensuring that the fndings of this report are used and its recommendations implemented so that we may indeed halt the rise in diabetes. The country profles (available online) were prepared by Melanie Cowan with assistance from Nisreen Abdel Latif, Maggie Awadalla, Sebastian Brown, Alison Commar, Karna Dhiravani, Jessica Sing Sum Ho, Kacem Iaych, Andre Ilbawi, Xin Ya Lim, Leanne Riley, Slim Slama and Juana Willumsen. Joel Tarel, Helene Dufays and Melissa Foxman Burns provided administrative support. James Bentham, Goodarz Danaei, Mariachiara Di Cesare, Majid Ezzati, Kaveh Hajifathalian, Vasilis Kontis, Yuan Lu and Bin Zhou for data analyses and estimates. David Beran, Stephen Colagiuri, Edward Gregg, Viswanathan Mohan, Ambady Ramachandran, Jeffrey Stephens, David Stuckler, John Yudkin, Nicholas Wareham, Rhys Williams and Ping Zhang for writing sections of the report. Both the number of cases and the prevalence of diabetes have been steadily increasing over the past few decades. The global prevalence (age-standardized) of diabetes has nearly doubled since 1980, rising from 4. This refects an increase in associated risk factors such as being overweight or obese. Over the past decade, diabetes prevalence has risen faster in low and middle-income countries than in high-income countries. The percentage of deaths attributable to high blood glucose or diabetes that occurs prior to age 70 is higher in low and middle-income countries than in high-income countries. Because sophisticated laboratory tests are usually required to distinguish between type 1 diabetes (which requires insulin injections for survival) and type 2 diabetes (where the body cannot properly use the insulin it produces), separate global estimates of diabetes prevalence for type 1 and type 2 do not exist. Possible complications include heart attack, stroke, kidney failure, leg amputation, vision loss and nerve damage. In pregnancy, poorly controlled diabetes increases the risk of fetal death and other complications. While the major cost drivers are hospital and outpatient care, a contributing factor is the rise in cost for analogue insulins1 which are increasingly prescribed despite little evidence that they provide signifcant advantages over cheaper human insulins. These are insulins derived from human insulin by modifying its structure to change the pharmacokinetic profle. Effective approaches are available to prevent type 2 diabetes and to prevent the complications and premature death that can result from all types of diabetes. These include policies and practices across whole populations and within specifc settings (school, home, workplace) that contribute to good health for everyone, regardless of whether they have diabetes, such as exercising regularly, eating healthily, avoiding smoking, and controlling blood pressure and lipids. Taking a life-course perspective is essential for preventing type 2 diabetes, as it is for many health conditions. Early in life, when eating and physical activity habits are formed and when the long-term regulation of energy balance may be programmed, there is a critical window for intervention to mitigate the risk of obesity and type 2 diabetes later in life. Easy access to basic diagnostics, such as blood glucose testing, should therefore be available in primary health-care settings. Established systems for referral and back-referral are needed, as patients will need periodic specialist assessment or treatment for complications. For those who are diagnosed with diabetes, a series of cost-effective interventions can improve their outcomes, regardless of what type of diabetes they may have. These interventions include blood glucose control, through a combination of diet, physical activity and, if necessary, medication; control of blood pressure and lipids to reduce cardiovascular risk and other complications; and regular screening for damage to the eyes, kidneys and feet, to facilitate early treatment. Diabetes management can be strengthened through the use of standards and protocols. Most countries report having national diabetes policies, as well as national policies to reduce key risk factors and national guidelines or protocols to improve management of diabetes. In some regions and among lower-income countries, however, these policies and guidelines lack funding and implementation. In general, primary health-care practitioners in low-income countries do not have access to the basic technologies needed to help people with diabetes properly manage their disease. Many countries have conducted national population-based surveys of the prevalence of physical inactivity and overweight and obesity in the past 5 years, but less than half have included blood glucose measurement in these surveys.

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Breastfeeding subsequent pregnancies (48) and ear family members about the prevention, may also confer longer-term metabolic lier progression to type 2 diabetes. Women with preex weight loss is recommended in the post the time of the 4 to 12-week postpar isting diabetes, especially type 1 diabe partum period. Reproductive-aged women ticular attention should be directed to with prediabetes may develop type 2 di hypoglycemia prevention in the setting Type 2 Diabetes abetes by the time of their next preg of breastfeeding and erratic sleep and Type 2 diabetes is often associated with nancy and will need preconception eating schedules. As in type 1 diabetes, insulin all women with diabetes of childbearing Ongoing evaluation may be performed requirements drop dramatically after potential should have family planning with any recommended glycemic test delivery. Lower blood pressure levels may S118 Management of Diabetes in Pregnancy Diabetes Care Volume 40, Supplement 1, January 2017 be associated with impaired fetal growth. Mayo K, Melamed N, Vandenberghe H, In a 2015 study targeting diastolic blood 450 Berger H. Preprandial ver Preventive Services Task Force and the National hypertension (52). Metformin they may cause fetal renal dysplasia, oli versus insulin for the treatment of gestational Postprandial versus preprandial blood glucose gohydramnios, and intrauterine growth monitoring in women with gestational diabetes diabetes. A comparison of glyburide and and infant birth weight: the Diabetes in Early diuretic use during pregnancy is not rec Pregnancy Study. The National Institute of Child insulin in women with gestational diabetes mel ommended as it has been associated Health and Human DevelopmentdDiabetes in litus. The pharmaco in early diabetic pregnancy and pregnancy out logic basis for better clinical practice. Optimal glycemic control, pre and insulin for the treatment of gestational dia control during early pregnancy and fetal malfor eclampsia, and gestational hypertension in betes: a systematic review and meta-analysis. Glycemic targets in the sec trauterine exposure to diabetes conveys risks analysis of randomized controlled trials. Association of adverse pregnancy outcomes congenital anomalies in the offspring of women levels are signicantly lower in early and late with glyburide vs insulin in women with ges with prepregnancy diabetes. Am J Obstet Gynecol 2015; by lifestyle intervention: the Finnish Gestational Cooperative Multicenter Reproductive Medi 212:74. Diabetes Care 2016;39: both for infertility in the polycystic ovary syn and Reproductive Health for Girls. Pregnancy outcome follow Fifth International Workshop-Conference on double-dummy controlled clinical trial compar ing exposure to angiotensin-converting enzyme Gestational Diabetes Mellitus. Diabetes Care ing clomiphene citrate and metformin as the inhibitors orangiotensinreceptorantagonists: a 2007;30(Suppl. Duration of lactation the effect of lifestyle intervention and metformin ovarian diathermy in clomiphene citrate-resistant and incidence of type 2 diabetes. American College of Obstetricians and Gy bolic control and progression of retinopathy. National necologists; Task Force on Hypertension in diabetes and the incidence of type 2 diabetes: a Institute of Child Health and Human Develop Pregnancy. Healthful dietary pat Medicine; Food and Nutrition Board; Board on 1131 Children, Youth, and Families; Committee to Re terns and type 2 diabetes mellitus risk among women with a history of gestational diabetes 52. B c Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold $180 mg/dL (10. C c Intravenous insulin infusions should be administered using validated written or computerized protocols that allow for predened adjustments in the insulin infusion rate based on glycemic uctuations and insulin dose. E c Basal insulin or a basal plus bolus correction insulin regimen is the preferred treatment for noncritically ill patients with poor oral intake or those who are taking nothing by mouth. An insulin regimen with basal, nutritional, and cor rection components is the preferred treatment for noncritically ill hospitalized patients with good nutritional intake. A c Sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged. A c A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for preventing and treating hypo glycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be documented in the medical record and tracked. E c the treatment regimen should be reviewed and changed as necessary to prevent further hypoglycemia when a blood glucose value is, 70 mg/dL (3. C c There should be a structured discharge plan tailored to the individual patient with diabetes. B In the hospital, both hyperglycemia and hypoglycemia are associated with adverse outcomes including death (1, 2). Therefore, inpatient goals should include the pre vention of both hyperglycemia and hypoglycemia. Hospitals should promote the shortest, safe hospital stay and provide an effective transition out of the hospital that prevents acute complications and readmission. For in-depth review of inpatient hospital practice, consult recent reviews that focus on hospital care for diabetes (3, 4). To correct this, hospitals have estab Suggested citation: American Diabetes Associa tion. In lished protocols for structured patient care and structured order sets, which include Standards of Medical Care in Diabetesd2017. Because inpatient insulin use (5) and discharge orders for prot, and the work is not altered. More infor (6) can be more effective if based on an A1C level on admission (7), perform an A1C mationisavailableat. In addition, diabetes self persistently above this level may require porated into the day-to-day decisions re management knowledge and behaviors alterations in diet or a change in medica garding insulin doses (2). Previously, In the patient who is eating meals, glu taking antihyperglycemic medications, hypoglycemia in hospitalized patients cose monitoring should be performed monitoring glucose, and recognizing has been dened as blood glucose before meals. A Cochrane review poglycemia is dened as that associated glucose monitoring that prohibit the of randomized controlled trials using with severe cognitive impairment regard sharing of ngerstick lancing devices, computerized advice to improve glucose less of blood glucose level (see Section 6 lancets, and needles (17). Electronic insulin order Moderate Versus Tight Glycemic questions about the appropriateness of templates also improve mean glucose Control these criteria, especially in the hospital levels without increasing hypoglycemia A meta-analysis of over 26 studies, in and for lower blood glucose readings in patients with type 2 diabetes, so struc cluding the Normoglycemia in Intensive (18). Any glucose Appropriately trained specialists or spe and mortality intightly versusmoderately result that does not correlate with the pa cialty teams may reduce length of stay, controlled cohorts (16).

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S96 Microvascular Complications and Foot Care Diabetes Care Volume 40, Supplement 1, January 2017 Evaluation for Peripheral Arterial neuroarthropathy is the best way to pre 8. The routine type 1 diabetes in the Diabetes Control and history of decreased walking speed, leg prescription of therapeutic footwear is Complications Trial and the Epidemiology of Di fatigue, claudication, and an assessment not generally recommended. General footwear recommenda in patients with type 2 diabetes and renal dis tions include a broad and square toe box, ease: a meta-analysis. Albuminuria changes and and sufficient size to accommodate a cush (history of ulcer or amputation, defor cardiovascular and renal outcomes in type 1 di ioned insole. Effect of inten about risk factors and appropriate man Most diabetic foot infections are poly sive diabetes treatment on albuminuria in agement (107). Patients at risk should type 1 diabetes: long-term follow-up of the Di microbial, with aerobic gram-positive understand the implications of foot de abetes Control and Complications Trial and cocci. Effect of intensive blood-glucose control unbreakable mirror) for surveillance of for infection with antibiotic-resistant with metformin on complications in overweight early foot problems. Intensivebloodglucose con venting movement, or cognitive problems of individuals with diabetes (109). Kidney Int of blood-pressure lowering and glucose control in increased plantar pressures. Canagliozinslowspro commercial therapeutic footwear, will re the United States. Re Liraglutide and cardiovascular outcomes in type 2 hot, swollen foot or ankle, and Charcot nal insufficiency in the absence of albuminuria and diabetes. Effects of treatment approach, and glycated haemoglobin of diabetic nephropathy in patients with type 2 di prior intensive insulin therapy and risk factors concentration on the risk of severe hypoglycae abetes. Diabetes mellitus as a compelling indication Epidemiology of Diabetes Interventions and Compli 24. Department of Health and Human Ser doxazosin to determine the optimal treatment 1319 vices. Accessed 15 October 2016 heart failure and diabetes mellitus and/or chronic for diabetic retinopathy. Tight for preventing the progression to end-stage kid clinical practice guidelines for the management blood pressure control and risk of macrovascu ney disease. Am J Kidney Dis 1998;31: 20-year prospective study of childbearing and inhibition on diabetic nephropathy. Diabetes Control and Complications Trial Re betic Retinopathy Study report number 1. Writing Committee for the Diabetic Reti sion of diabetic peripheral neuropathy in the 100. Neuropathy and related Pharmacotherapy for neuropathic pain in randomized withdrawal, placebo-controlled ndings in the Diabetes Control and Complica adults: a systematic review and meta-analysis. Pharmacologic interventions for painful Therapy for Diabetes Mellitus and Related Dis 78.

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To do so, they distinguish between three dimensions: the decision whether or not to have a child; the decision to reduce working time; and the decision about which of the parents reduces their working time, at which point in time and for how long. The Elterngeld considerably changed the amount of transfers to families during the first two years postpartum. The article shows that the incentives created by using a cut-off date led more than 1, 000 parents to postpone the delivery of their children from December 2006 to January 2007. Concerning potential adverse impacts on health outcomes of children we find a slight increase in average birth weight and the rate of children with high birth weight. The study evidences substantial regional and local variations in the quality of childcare, largely due to a lack of a national quality standards and a national monitoring system. Private sector (responsibility of the Department of Labour, Social Security and Welfare) a. Due to the fact that such Agreements cannot include worse provisions than the minimum standards included in the National General Collective Agreement, they usually have improved provisions for working parents. Flexibility in use Basic leave: none except for when leave can start: if birth takes place before the time envisaged, the rest of the leave can be granted after birth so long as the total time taken remains 17 weeks. Eligibility Basic leave: to ensure full compensation, 200 working days during the previous two years are needed. Parental leave ( ) Length of leave Four months per child for each parent. In which case, leave is granted by the employer according to a set of priorities; requests for Parental leave from parents of children with a disability or long-term illness or sudden illness and from single parents (due to the death of parent, total removal of parental responsibility or non-recognition of the child) are dealt with as an absolute priority. Childcare leave or career breaks A parent can take time off work with full payment, up to an estimated three and three quarter months, as part of a scheme which also allows parents to work reduced hours. Other employment-related measures Adoption leave and pay For parents that adopt or foster a child that is younger that six years of age (with an extension to eight years of age if adoption or fostering procedures are not finished), the same regulations for Parental leave apply as for other parents. Individual right Leave for parents due to the hospitalisation of a child (up to 18 years of age), which requires their immediate presence: up to 30 days per year unpaid leave on the condition that the parent has exhausted his/her normal Parental leave. Flexible working Parents are entitled to work one hour less per day for up to 30 months after Maternity leave, with full earnings replacement. This last option, of converting reduced hours into a block or blocks of leave, means that a parent can take a number of months off work, up to an estimated three and three-quarter months. Maternity leave ( ) Length of leave (before and after birth) Five months: two months must be taken before birth and three after birth. For every child after the third, the length of post-natal leave is extended by two. Flexibility in use If birth takes place before the time envisaged, the rest of the leave can be granted after birth so long as the total time taken remains five months. If birth takes place after the time envisaged, the leave is extended until the actual birth date without any respective reduction in the after birth leave. Parental leave ( ) Length of leave Up to two years per parent. Payment and funding None, except for the case of three or more children where three months of the leave are fully paid by the employer and funded through general taxation. Flexibility in use Leave may be taken at any time up to the time the child turns six years. The leave is paid by the employer and funded through general taxation, and is granted after Maternity leave. The leave does not constitute a personal entitlement and can be used by either or both parents within the total nine month period. For a parent who is unmarried, widowed, divorced or has a severely disabled child, the leave is extended by one month. Other employment-related measures Adoption leave and pay Adoptive mothers are granted a three month paid leave during the first six months after the adoption if the child is less than six years of age. Flexible working Parents are entitled to work two hours less per day if he/she has children of less than two years old and one hour less per day if he/she has children between two and four years old, with full earnings replacement. As mentioned above (1iid) there is an alternative option for this leave which is nine consecutive months off work after Maternity leave. In the case of the birth of a fourth child, flexible working is further extended by two years. Relationship between leave policy and early childhood education and care policy the maximum period of post-natal leave available in Greece is 60 months in the public sector and 20 months in the private sector; but leave paid at a high rate runs for only 6 months in the private sector and 12 months in the public sector. Moreover, the minimum wage has been reduced by 22 per cent (32 per cent in the case of young labour market entrants) and is no more the outcome of collective bargaining but set by state. Regarding parental rights in particular, the lowering of the minimum wage had an impact on benefits that are relate to it, like maternity benefit and the special leave for the protection of maternity. At the same time, leave take-up has been negatively affected by the severe deterioration in employment and working conditions. In the same report, the Ombudsman identifies, however, a tendency on the part of mothers to solve their problems privately with their employers, accepting in effect the violation of their rights for fear of losing their jobs. But even those that complain to the Ombudsman are hesitant to proceed to further action and sometimes they withdraw the complaint. On the positive side of developments, a new law on Parental leave was voted by the Greek Parliament in April 2012 (articles 48-54, Law 4075/12), and immediately implemented. The Ombudsman reports also other successful interventions to public authorities that referred to the interpretation of certain provisions of the existing legislation or gaps in legislation. Although not directly related to leave policies, an important development in late 2012 (Law 4093/12) concerns the non-contributory family benefits. On the positive side of this development, we record the extension of these benefits to all families with children instead of only families with 3+ or 4+ children as was the case before. However, much stricter means rd testing criteria were introduced, while the quite generous 3 child benefits were abolished. Take-up of leave There is no information on take-up of the various types of leave.

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