By C. Rendell. Northwest Christian College.

The 2017 Standards of uled just before the standard 6-week post- bohydrate counting for some patients to Care contains buy dramamine 50 mg with visa, in addition to many minor partum obstetrical checkup so that the reflect evidence that these dietary fac- changes that clarify recommendations or results can be discussed with the patient tors influence insulin dosing and blood reflect new evidence purchase dramamine 50 mg line, the following more at that time of the visit or to allow the test glucose levels. Promoting Health and section on monogenic diabetes syn- interrupted every 30 min with short Reducing Disparities in Populations dromes, and a new table was added (Ta- bouts of physical activity. A new section and table provide infor- Recommendations were added to as- mation on situations that might warrant Section 3. Comprehensive Medical sess patients’ social context as well as referral to a mental health provider. Evaluation and Assessment of refer to local community resources and Comorbidities Section 5. Classification and Diagnosis of the 2016 section “Foundations of To help providers identify those patients of Diabetes Care and Comprehensive Medical Eval- who would benefit from prevention ef- The section was updated to include a uation,” highlights the importance of forts, new text was added emphasizing new consensus on the staging of type 1 assessing comorbidities in the context the importance of screening for prediabe- diabetes (Table 2. The Standards of Care now recom- association between B12 deficiency and Language was added to clarify screen- mends the assessment of sleep pattern long-term metformin use, a recommen- ing and testing for diabetes. Screening and duration as part of the comprehensive dation was added to consider periodic © 2017 by the American Diabetes Association. 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. Children and Adolescents to reflect studies demonstrating the non- Based on recommendations from the In- Additional recommendations highlight inferiority of basal insulin plus glucagon- ternational Hypoglycaemia Study Group, the importance of assessment and re- like peptide 1 receptor agonist versus basal serious, clinically significant hypoglycemia ferral for psychosocial issues in youth. Obesity Management for conception counseling starting at puberty Due toconcernsabout the affordability the Treatment of Type 2 Diabetes for all girls of childbearing potential. Management of Diabetes four classes of blood pressure medications for surgical candidacy (Table 7. Pharmacologic Approaches that have shown beneficial cardiovascular the fetal side of the placenta and glyburide to Glycemic Treatment outcomes may be used. The title of this section was changed from To optimize maternal health without Based on available data, preprandial “Approaches to Glycemic Treatment” to risking fetal harm, the recommendation self-monitoring of blood glucose was “Pharmacologic Approaches to Glycemic for the treatment of pregnant patients deemphasized in the management of Treatment” to reinforce that the section with diabetes and chronic hypertension diabetes in pregnancy. A section was added describing the cardio- with gestational diabetes mellitus and To reflect new evidence showing an as- vascular outcome trials that demonstrated preexisting diabetes were unified. Diabetes Care in the was added to consider periodic measure- Hospital ment of B12 levels and supplementation Section 10. Complications and Foot Care A treatment recommendation was up- A section was added describing the A recommendation was added to high- dated to clarify that either basal insulin or role of newly available biosimilar insu- light the importance of provider commu- basal plus bolus correctional insulin lins in diabetes care. S6 Diabetes Care Volume 40, Supplement 1, January 2017 American Diabetes Association 1. Prom oting ealth and educing D isparities in Populations Diabetes Care 2017;40(Suppl. B c Providers should consider the burden of treatment and self-efficacy of pa- tients when recommending treatments. E c Treatment plans should align with the Chronic Care Model, emphasizing pro- ductive interactions between a prepared proactive practice team and an in- formed activated patient. A c When feasible, care systems should support team-based care, community in- volvement,patient registries, and decisionsupport tools to meet patient needs. Thus, efforts to improve population health will require a combination of system-level and patient-level approaches. Practice recommendations, whether based on evidence or expert opinion, are intended to guide an overall ap- proach to care. The science and art of medicine come together when the clinician is faced with making treatment recommendations for a patient who may not meet the eligibility criteria used in the studies on which guidelines are based. Recognizing that one size does not fit all, the standards presented here provide guidance for when and how to adapt recommendations for an individual. This has been accompanied by improvements in cardiovascular out- comes and has led to substantial reductions in end-stage microvascular complications. Nevertheless, 33–49% of patients still do not meet targets for glycemic, blood pressure, or cholesterol control, and only 14% meet targets for all three measures while also avoiding smoking (2). Evidence suggests that progress in cardiovascular risk factor control (particularly tobacco use) may be slowing (2,3). Certain segments Suggested citation: American Diabetes Associa- of the population, such as young adults and patients with complex comorbidities, tion. Promoting health and reducing disparities financial or other social hardships, and/or limited English proficiency, face particular in populations. Readers may use this article as long as the work is properly cited, theuseiseducationalandnotfor Chronic Care Model profit, and the work is not altered. More informa- Numerous interventions to improve adherence to the recommended standards tion is available at http://www. If pressure, or lipids were associated with adherence is 80% or above, then treat- poor medication adherence (15). Delivery system design (moving ment intensification should be con- to adherence may include patient factors from a reactive to a proactive care sidered (e.

More research is needed to determine if behavioral therapies can be used to treat Behavioral Therapies addiction to hallucinogens 50mg dramamine mastercard. Anxiety buy dramamine 50 mg cheap, confusion, insomnia, mood problems, violent behavior, paranoia, Long-term hallucinations, delusions, weight loss, severe dental problems (“meth mouth”), Consequences of Use memory loss, intense itching leading to skin sores from scratching and high-risk for and Health Effects addiction. Issues Pregnancy-related: premature delivery; separation of the placenta from the uterus; low birth weight; lethargy; heart and brain problems. In Combination with Masks the depressant effect of alcohol, increasing risk of alcohol overdose; may Alcohol increase blood pressure and jitters. More research is needed to determine if behavioral therapies can be used to treat Behavioral Therapies addiction to over-the-counter cough/cold medicines. Dissociative drugs are hallucinogens that cause the user to feel detached from reality. Low doses: slight increase in pulse and breathing rate; increased blood pressure and Short-term Symptoms heart rate; shallow breathing; face redness and sweating; numbness of the hands or of Use feet; and loss of coordination. High doses: lowered blood pressure, heart rate, and breathing; nausea; vomiting; blurred vision; ficking up and down of the eyes; drooling; loss of balance; dizziness; violence; suicidal thoughts; seizures, coma, and death. Long-term Memory loss, problems with speech and thinking, depression, psychosis, weight loss, Consequences of Use anxiety. Opioids can cause euphoria and are sometimes used nonmedically, leading to overdose deaths. Short-term Symptoms For oxycodone specifcally: Pain relief, sedation, respiratory depression, constipation, of Use papillary constriction, and cough suppression. For fentanyl specifcally: Fentanyl is about 100 times more potent than morphine as an analgesic and results in frequent overdoses. Extended or chronic use of oxycodone containing Consequences of Use acetaminophen may cause severe liver damage. Abuse of opioid medications can lead and Health Effects to psychological dependence. Older adults: higher risk of accidental misuse or abuse because many older adults have Other Health-related multiple prescriptions, increasing the risk of drug-drug interactions, and breakdown of Issues drugs slows with age; also, many older adults are treated with prescription medications for pain. In Combination with Dangerous slowing of heart rate and breathing leading to coma or death. Alcohol Withdrawal Restlessness, anxiety, muscle and bone pain, insomnia, diarrhea, vomiting, cold fashes Symptoms with goose bumps, and muscle tremors. Treatment Optionsiv • Methadone Medications • Buprenorphine • Naltrexone (oral and extended-release injectable) Behavioral therapies that have helped treat addiction to heroin may be useful in Behavioral Therapies treating prescription opioid addiction. In Combination with Dangerous slowdown of heart rate and breathing, coma, and death. Alcohol Must be discussed with a health care professional; barbiturate withdrawal can Withdrawal Symptoms cause a serious abstinence syndrome that may even include seizures. More research is needed to determine if behavioral therapies can be used to treat Behavioral Therapies addiction to prescription sedatives. Short-term Symptoms of Use High doses: dangerously high body temperature and irregular heartbeat; seizures; and death from heart failure or suicide. For amphetamines specifcally: Paranoia, picking at the skin, preoccupation with one’s own thoughts, and auditory and visual hallucinations. Long-term Consequences of Use Heart problems, psychosis, anger, paranoia, addiction, and chronic sleep problems. Issues In Combination with Masks the depressant action of alcohol, increasing risk of alcohol overdose; may Alcohol increase blood pressure and jitters. Behavioral therapies that have helped treat addiction to cocaine or methamphetamine Behavioral Therapies may be useful in treating prescription stimulant addiction. More research is needed to determine if psilocybin is addictive and whether Behavioral Therapies behavioral therapies can be used to treat addiction to this or other hallucinogens. Teens and young adults tend to abuse this drug at bars, nightclubs, concerts, and parties. It has been used to commit sexual assaults due to its ability to sedate and incapacitate unsuspecting victims. Long-term Consequences of Use Physical and psychological dependence; cardiovascular collapse; and death and Health Effectsiii Other Health-related Sometimes used as a date rape drug. Issues In Combination with Exaggerated intoxication, severe sedation, unconsciousness, and slowed heart rate Alcohol and breathing, which can lead to death. Headache; muscle pain; extreme anxiety, tension, restlessness, confusion, irritability; Withdrawal Symptoms numbness and tingling of hands or feet; hallucinations, delirium, convulsions, seizures, or shock. More research is needed to determine if behavioral therapies can be used to treat Behavioral Therapies addiction to Rohypnol® or other prescription sedatives. More research is needed to determine if salvia is addictive, but behavioral therapies Behavioral Therapies can be used to treat addiction to dissociative drugs. Kidney damage or failure; liver damage; high blood pressure, enlarged heart, or Long-term changes in cholesterol leading to increased risk of stroke or heart attack, even in Consequences of Use young people; hostility and aggression; extreme mood swings; anger (“roid rage”); and Health Effects paranoid jealousy; extreme irritability; delusions; impaired judgment. Males: shrunken testicles, lowered sperm count, infertility, baldness, development of Other Health-related breasts, increased risk for prostate cancer.

See page 32 for an expanded description of the symptoms of Stevens-Johnson syndrome order 50mg dramamine with mastercard. Stud- ies are not conclusive as to whether these medications will help to prevent future episodes of bipolar disorder purchase 50mg dramamine mastercard. A recent study among children and adolescents aged 10 to 17 showed that this medication was effective in controlling the acute manic symptoms of bipolar disorder children and adolescents. A recent study among children and adolescents aged 10 to 17 years old showed that this drug was effective in controlling the acute symptoms of mania and mixed mania. This medica- tion was indicated in 2003 for the treatment of the depressive episodes of bipolar I disorder in adults. For example, in addition to being approved for children and adolescents aged 10 to 17 with bipolar mania or mixed mania, aripiprazole, risperidone, and olanzapine have been approved for treatment of schizophrenia in adolescents aged 13 to 17. Also, risperidone and apripiprazole are approved to treat the aggression and irritability associated with autistic disorder in children and adolescents aged 6 to 17. It appears that children and adolescents are more sensitive to the side effects of medications used for bipolar disorder than are adults. Caution also should be taken when giving a child or adolescent other medication while he or she is taking an atypical antipsychotic. Antihy- pertensive medications (such as Aldomet®, Procardia®, Vasotec®, and Lasix®) can cause a sudden drop in blood pressure. Over-the-counter cold and allergy medications may cause an increase in the sedative effects of atypical antipsy- chotic medication. In addition, caffeine and cigarettes can reduce the effective- ness of atypical antipsychotics. Ask your child’s doctor about potential drug interactions before taking any prescribed or over-the-counter medications. Mild to Moderate Side Effects Mild to moderate side effects common among atypical antipsychotics include: • Akathisia (restlessness) • Dizziness or fainting spell due to decrease in blood pressure when standing up (orthostasis) • Increased appetite • Weight gain • Tiredness • Drowsiness • Nausea • Heartburn • Night tremors • Decreased sexual interest Rapid weight gain is a well-recognized side effect from most atypical antipsy- chotics medications. If your child has gained weight while taking an atypical antipsychotic, consult with your child’s doctor and a dietician to create a plan that helps manage weight gain. More information about medication weight gain can be found on page 50 of this guide. In addition, many atypical antipsychotics medications increase the risk for seizures, especially at high doses. Patients with epilepsy should be closely monitored while taking these medications. It consists of marked muscle stiff- ness, high fever, racing heart beat, fainting spells, and a general sense of feeling very ill. This syndrome is more likely to occur when high doses of antipsychotic medication are prescribed, or when the dose is in- creased rapidly. If your child or adolescent is taking an atypical or typical antipsychotic and is active in sports or plays outside on very hot days, make sure he or she drinks plenty of liquids. Metabolic Syndrome Metabolic syndrome is a collection of risk factors that increase the likelihood of a person developing cardiovascular disease and/or diabetes. Many who take atypical antipsychotics have problems with metabolism, including weight gain, high blood sugar (causing diabetes), and high blood fat (lipids) are potential side effects that pose serious health risks. Children and adolescents are particu- larly sensitive to weight gain associated with atypical antipsychotics. Atypical antipsychotics differ in their short- and long-term effects on weight gain. Some research suggests that most of the weight gain occurs within the frst 6 months of taking an atypical antipsychotic. The information contained in this guide is not intended as, and is not a substitute for, professional medical ParentsMedGuide. Some common typical antipsychotics include haloperidol (Haldol®), chlorpromazine (Thorazine®), perphenazine (Trilafon®), and molindone (Moban®). These medications have been shown effective in adults for treatment of bipolar mania as well as bipolar psychosis. While some children and adoles- cents are still prescribed typical antipsychotics, most child and adolescents psychiatrists prefer to use atypical antipsychotics. Typical antipsychotics are associated with high rates of side effects, such as muscle stiffness, and tremor, restlessness of the legs (akathisia), involuntary muscle movements [tardive dyskinesia], and high levels of prolactin (a hor- mone that affects sexual development and function). This syndrome is more likely to occur when high doses of antipsychotic medication are prescribed, or when the dose is increased rapidly. If your child or adolescent is taking a typi- cal or atypical antipsychotic and is active in sports or plays outside on very hot days, make sure he or she drinks plenty of liquids. There are no large clinical trials that show that typical antipsychotics are safe and effective in children and adolescents with bipolar disorder. For this reason, typical antipsychotics are not commonly used to treat the symptoms of bipolar disorder. In most cases, these medications are taken along with an atypical antipsychotic or a mood stabilizer. Some of the medications that may be prescribed for the collateral symptoms of bipolar disorder in children and adolescents include: • Antidepressants in combination with a mood stabilizer: Sometimes anti- depressants are prescribed to treat the depressive phase of bipolar disorder or to treat a coexisting condition, such as anxiety.

Isoniazid is given daily for six to nine months and the protective effect is expected to last for 18 months generic 50mg dramamine free shipping. The main clinical features include fever and generalized maculopaular (Red rash appearing first behind the ears and spreading to rest of body) plus any of the following: Cough dramamine 50mg generic, runny nose or conjunctivitis. Others include lacrimation, photophobia, and copius nasal discharge, koplik spots, tearing and eyelid oedema. It is caused by one of the three related polio viruses, types 1, 2 and 3 which comprise a subdivision of the groups of enteroviruses. Treatment guidelines Give supportive therapy Prevention  This disease is preventable by immunization with polio vaccine starting at birth. It is almost always caused by one or another of the hepatitis viruses; A, B, C, and delta viruses. These ranges from asymptomatic and inapparent to fulminant and fatally acute infections. Subclinical persistent infections with hepatitis virus B and C may progress to chronic liver disease, cirrhosis and possible hepatocellurlar carcinoma. Treatment guidelines Treatment is mainly supportive; the condition can be self-limiting (healing on its own) or can progress to fibrosis (scarring) and cirrhosis. Clinical presentation  History of direct exposure to a previously jaundiced individual. Differential diagnosis Before jaundice appears, the symptoms are those of non-specific enteroviral diseases Note: Hepatitis mainly resolves spontaneously (95%) but rarely complicates into fulminant Hepatitis that is fatal. Elevated alkaline phosphatase, gamma glutamic acid and total and direct (conjugated) bilirubin levels are indicators of the degree of cholestasis, which may be a result of hepatocellular and bile duct damage. Prevention General measures: Sanitation and hygiene that includes hand washing, proper disposal of infectious materials. Mode of transmission Mainly through parenteral, sexual and vertical transmission 5% Clinical presentation  The symptoms are non-specific, consisting only of slight fever (which may be absent) and mild gastrointestinal upset  Visible jaundice is usually the first significant finding  Dark urine and pale or clay-coloured stools  Hepatomegaly is present  Occasionally a symptom complex (caused by antigen-antibody complexes) of macular rash, urticarial lesion, and arthiritis antedates the appearance of icterus. Treatment  Supportive o Low fat diet, oral fluids, o Give paracetamol (dose as above) if pain present  Specific treatment o The use of interferon alfa in children has not yet established. Acute infection is often milder than Hepatitis A with moderately raised transaminases. Rabies Rabies is a zoonotic (transmitted from animals) viral neuroinvasive disease caused by a virus that belongs to genus lyssavirus in the family Rhabdoviridae. It is transmitted most commonly to human by a bite from an infected animal but occasionally by other forms of contact. Rabies is almost invariably fatal if post-exposure prophylaxis is not administered prior to the onset of severe symptoms. The incubation period of the disease depends on how far the virus must travel to reach the central nervous system, may take one week to six months. Once the infection reaches the central nervous system and symptoms begin to show, the infection is practically untreatable and usually fatal within days. Early-stage symptoms of rabies are malaise, headache and fever, later progressing to more serious ones, including acute pain, violent movements, uncontrolled excitement, depression and inability to swallow water. Finally, the patient may experience periods of mania and lethargy, followed by coma. In unvaccinated humans, rabies is almost always fatal after neurological symptoms have developed, but prompt post-exposure vaccination may prevent the virus from progressing. For rabies-exposed patients who have previously undergone complete pre-exposure vaccination or post-exposure treatment with cell-derived rabies vaccines, antirabies vaccines are given at days 0 and 3 regardless of route of administration i. The same rules apply to persons vaccinated against rabies who have demonstrated neutralizing antibody titres of at least 0. Transmission The natural reservoir of the virus is unknown, the manner in which the virus first appears in a human at the start of an outbreak has not been determined. Researchers have hypothesized that the first patient becomes infected through contact with an infected animal. After the first case-patient in an outbreak setting is infected, the virus can be transmitted in several ways: – Direct contact with blood or other secretions of an infected person (blood, secretions, organs or other bodily fluids) – Exposure to Ebola virus through contact with objects, such as needles, that has been contaminated with infected secretions. Signs and symptoms start with sudden onset of fever, intense weakness, muscle pain, Headache and Sore throat. These symptoms are followed by vomiting, diarrhea, rash, impaired kidney and liver functions. In some cases; rash, red eyes, hiccups, both internal and external bleeding can occur. Treatment There is no specific treatment, cure, or vaccine for Marburg Hemorrhagic fever. These include: o Fluid and Electrolyte balancing o Maintaining oxygen status o Blood transfusion and clotting factors o Treat for any complicating infections.