Source As they age 10 purchase hydrochlorothiazide in india, sons are given tasks that take them outside the house and that have to be performed only on occasion heart attack pulse order hydrochlorothiazide in india, while girls are more likely to be given chores inside the home pulse pressure in cardiac tamponade cheap 12.5 mg hydrochlorothiazide visa, such as cleaning or cooking that are performed daily heart attack xi order hydrochlorothiazide canada. Sons are encouraged to think for themselves when they encounter problems and daughters are more likely to be given assistance blood pressure young age cheap hydrochlorothiazide amex, even when they are working on an answer pulse pressure variation critical care purchase generic hydrochlorothiazide pills. For example hypertension with stage v renal disease order hydrochlorothiazide without prescription, parents talk to sons more in detail about science blood pressure of 110/70 discount hydrochlorothiazide 12.5mg overnight delivery, and they discuss numbers and counting twice as often than with daughters (Chang, Sandhofer, & Brown, 2011). How are these beliefs about behaviors and expectations based on gender transmitted to childrenfi Theories of Gender Development One theory of gender development in children is social learning theory, which argues that behavior is learned through observation, modeling, reinforcement, and punishment (Bandura, 1997). Children are rewarded and reinforced for behaving in concordance with gender roles that have been presented to them since birth and punished for breaking gender roles. In addition, social learning theory states that children learn many of their gender roles by modeling the behavior of adults and older children and, in doing so, develop ideas about what behaviors are 141 appropriate for each gender. Cognitive social learning theory also emphasizes reinforcement, punishment, and imitation, but adds cognitive processes. Once children learn the significance of gender, they regulate their own behavior based on internalized gender norms (Bussey & Bandura, 1999). Another theory is that children develop their own conceptions of the attributes associated with maleness or femaleness, which is referred to as gender schema theory (Bem, 1981). Once children have identified with a particular gender, they seek out information about gender traits, behaviors, and roles. This theory is more constructivist as children are actively acquiring their gender. For example, friends discuss what is acceptable for boys and girls, and popularity may be based on what is considered ideal behavior for their gender. Developmental intergroup theory states that many of our gender stereotypes are so strong because we emphasize gender so much in culture (Bigler & Liben, 2007). Transgender Children Many young children do not conform to the gender roles modeled by the culture and even push back against assigned roles. However, a small percentage of children actively reject the to ys, clothing, and ana to my of their assigned sex and state they prefer the to ys, clothing and ana to my of the opposite sex. Transgender adults have stated that they identified with the opposite gender as soon as they began talking (Russo, 2016). Current research is now looking at those young children who identify as transgender and have socially transitioned. In 2013, a longitudinal study following 300 socially transitioned transgender children between the ages of 3 and 12 began (Olson & Gulgoz, 2018). Socially transitioned transgender children identify with the gender opposite than the one assigned at birth, and they change their appearance and pronouns to reflect their gender identity. Findings from the study indicated that the gender development of these socially transitioned children looked similar to the gender development of cisgender children, or those whose gender and sex assignment at birth matched. These socially transitioned transgender children exhibited similar gender preferences and gender identities as their gender matched peers. Further, these children who were living everyday according to their gender identity and were supported by their families, exhibited positive mental health. Some individuals who identify as transgender are intersex; that is born with either an absence or some combination of male and female reproductive organs, sex hormones, or sex chromosomes (Jarne & Auld, 2006). There are dozens of intersex conditions, and intersex individuals demonstrate the diverse variations of biological sex. How much does gender matter for children: Starting at birth, children learn the social meanings of gender from adults and their culture. Therefore, when children make choices regarding their gender identification, expression, and behavior that may be contrary to gender stereotypes, it is important that they feel supported by the caring adults in their lives. This support allows children to feel valued, resilient, and develop a secure sense of self (American Academy of Pediatricians, 2015). Preschool and grade-school children are more capable, have their own preferences, and sometimes refuse or seek to compromise with parental expectations. This can lead to greater parent-child conflict, and how conflict is managed by parents further shapes the quality of parent-child relationships. This kind of parenting style has been described as authoritative (Baumrind, Source 2013). Parents allow negotiation where appropriate, and consequently this type of parenting is considered more democratic. Authoritarian is the traditional model of parenting in which parents make the rules and children are expected to be obedient. Baumrind suggests that authoritarian parents tend to place maturity demands on their children that are unreasonably high and tend to be aloof and distant. Consequently, children reared in this way may fear rather than respect their parents and, because their parents do not allow discussion, may take out their frustrations on safer targets perhaps as bullies to ward peers. Permissive parenting involves holding expectations of children that are below what could be reasonably expected from them. Parents are warm and communicative but provide little structure for their children. Children fail to learn self-discipline and may feel somewhat insecure because they do not know the limits. These children can suffer in school and in their relationships with their peers (Gecas & Self, 1991). Sometimes parenting styles change from one child to the next or in times when the parent has more or less time and energy for parenting. Parenting styles can also be affected by concerns the parent has in other areas of his or her life. For example, parenting styles tend to become more authoritarian when parents are tired and perhaps more authoritative when they are more energetic. Additionally, parenting styles may reflect the type of parenting someone saw modeled while growing up. The model of parenting described above assumes that the authoritative style is the best because this style is designed to help the parent raise a child who is independent, self-reliant and responsible. Authoritarian parenting has been used his to rically and reflects cultural need for children to do as they are to ld. African-American, Hispanic and Asian parents tend to be more authoritarian than non-Hispanic whites. In a classic study on social class and parenting styles, Kohn (1977) explains that parents tend to emphasize qualities that are needed for their own survival when parenting their children. Working class parents are rewarded for being obedient, reliable, and honest in their jobs. They are not paid to be independent or to question the management; rather, they move up and are considered good employees if they show up on time, do their work as they are to ld, and can be counted on by their employers. Middle class parents who work as professionals are rewarded for taking initiative, being self-directed, and assertive in their jobs. These parents encourage their children to have those qualities as well by rewarding independence and self-reliance. Spanking Spanking is often thought of as a rite of passage for children, and this method of discipline continues to be endorsed by the majority of parents (Smith, 2012). Gershoff, (2008) reviewed decades of research and recommended that parents and caregivers make every effort to avoid physical punishment and called for the banning of physical discipline in all U. Measures of externalizing behavior and receptive vocabulary were assessed at age nine. Results indicated that those children who were spanked at least twice a week by their mothers scored 2. When fathers did the spanking, those spanked at least two times per week scored 5. This study revealed the negative cognitive effects of spanking in addition to the increase in aggressive behavior. Cooperative and pretend play interactions between younger and older siblings can teach empathy, sharing, and cooperation (Pike, Coldwell, & Dunn, 2005), as well as, negotiation and conflict resolution (Abuha to um & Howe, 2013). However, the quality of sibling relationships is often mediated by the quality of the Source: parent-child relationship and the psychological adjustment of the child (Pike et al. For instance, more negative interactions between siblings have been reported in families where parents had poor patterns of communication with their children (Brody, S to neman, & McCoy, 1994). Children who have emotional and behavioral problems are also more likely to have negative interactions with their siblings. However, the psychological adjustment of the child can sometimes be a reflection of the parent-child relationship. Thus, when examining the quality of sibling interactions, it is often difficult to tease out the separate effect of adjustment from the effect of the parent-child relationship. Dunn and Munn (1987) revealed that over half of all sibling conflicts in early childhood were disputes about property rights. By middle childhood this starts shifting to ward control over social situation, such as what games to play, disagreements about facts or opinions, or rude behavior (Howe, Rinaldi, Jennings, & Petrakos, 2002). Researchers have also found that the strategies children use to deal with conflict change with age, but this is also tempered by the nature of the conflict. However, younger siblings also use reasoning, frequently bringing up the concern of legitimacy. This is a very common strategy used by younger siblings and is possibly an adaptive strategy in order for younger siblings to assert their au to nomy (Abuha to um & Howe, 2013). A number of researchers have found that children who can use non-coercive strategies are more likely to have a successful resolution, whereby a compromise is reached and neither child feels slighted (Ram & Ross, 2008; Abuha to um & Howe, 2013). Not surprisingly, friendly relationships with siblings often lead to more positive interactions with peers. Vygotsky and Piaget saw play as a way of children developing their intellectual abilities (Dyer & Moneta, 2006). Parten (1932) observed two to five-year-old children and noted six types of play: Three labeled as non-social play (unoccupied, solitary, and onlooker) and three categorized as social play (parallel, associative, and Source cooperative). Younger children engage in non-social play more than those older; by age five associative and cooperative play are the most common forms of play (Dyer & Moneta, 2006). Solitary Play Children play by themselves, do not interact with others, nor are they engaging in similar activities as the children around them. They may comment on the activities and even make suggestions but will not directly join the play. Parallel Play Children play alongside each other, using similar to ys, but do not directly act with each other. Associative Play Children will interact with each other and share to ys but are not working to ward a common goal. Some studies include only invisible characters that the child refers to in conversation or plays with for an extended period of time. Other researchers also include objects that the child personifies, such as a stuffed to y or doll, or characters the child impersonates every day. Estimates of the number of children who have imaginary companions varies greatly (from as little as 6% to as high as 65%) depending on what is included in the definition (Gleason, Sebanc, & Hartup, 2000). Imaginary companions are sometimes based on real people, characters from s to ries, or simply names the child has heard (Gleason, et. In addition, research suggests that contrary to the assumption that children with imaginary companions are compensating for poor social skills, several studies have found that these children are very sociable (Mauro, 1991; Singer & Singer, 1990; Gleason, 2002). However, studies have reported that children with imaginary companions are more likely to be first-borns or only-children (Masih, 1978; Gleason et al. Although not all research has found a link between birth order and the incidence of imaginary playmates (Manosevitz, Prentice, & Wilson, 1973). Moreover, some studies have found little or no difference in the presence of imaginary companions and parental divorce (Gleason et al. Young children view their relationship with their imaginary companion to be as supportive and nurturing as with their real friends. Gleason has suggested that this might suggest that children form a schema of what is a friend and use this same schema in their interactions with both types of friends (Gleason, et al. For children age six and under, two-thirds watch television every day, usually for two hours (Rideout & Hamel, 2006). Even when involved in other activities, such as playing, there is often a television on nearby (Christakis, 2009; Kirkorian, Pempek, & Murphy, 2009). An additional concern is the amount of screen time children are getting with smart mobile devices. While most parents believe that their young children use mobile devices for a variety of activities, the children report that they typically use them to play games (Chiong & Schuler, 2010). Studies have reported that young children who have two or more hours per day using mobile devices show more externalizing behaviors (aggression, tantrums) and inattention (Tamana, et al. The immaturity of the cognitive functions in infants and to ddlers make it difficult for them to learn from digital media as effectively as they can from caregivers. For instance, it is often not until 24 months of age that children can learn new words from live-video chatting (Kirkorian, Choi, & Pempek, 2016). Since more women have been entering the workplace, there has been a concern that families do not spend as much time with their children. The Economist Data Team (2017) analyzed data from of ten countries (United States, Britain, Canada, France, Germany, Denmark, Italy, Netherlands, Slovenia and Spain) and estimated that the average mother spent 54 minutes a day caring for children in 1965, but 104 minutes in 2012. Men continue to do less than women at 59 minutes per day in 2012, but they provided more care than in 1965 when they averaged only 16 minutes a day. However, Source differences were found between working-class and middle-class mothers. In 1965 mothers with and without a university education spent about the same amount of time on child care. This study is considered the most comprehensive child care study to date, and it began in 1991 when the children were one month of age. The study included an economically and ethnically diverse group of 1364 children assessed from 10 sites around the country. By design the study involved single parents, minority backgrounds, and differing formal education levels. Overall results indicated that children cared for by their mothers did not develop differently than those who were cared for by others. Parents and family characteristics were stronger predic to rs of child development than child care facilities. Specifically, greater cognitive, language and social competence were demonstrated when parents were more educated, had higher incomes, and provided emotionally supportive and cognitively enriched home environments. When comparing higher quality child care with lower quality child care differences were noted. Lower quality care predicted more behavioral problems and poorer cognitive, language, and school readiness.
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Thus heart attack grill dallas cheap hydrochlorothiazide 25 mg otc, especially where screening ings are much the same as for incidence examinations are prevalent prehypertension 2016 buy hydrochlorothiazide 12.5 mg without a prescription, recorded inci [1] blood pressure chart diabetes generic hydrochlorothiazide 25mg on line. Similar changes ment of population screening pro Prostate cancer is the third most common have been observed in Australia hypertension signs and symptoms treatment buy hydrochlorothiazide american express, Finland grammes in different populations blood pressure high heart rate low order generic hydrochlorothiazide pills. However blood pressure quizlet purchase 25 mg hydrochlorothiazide with amex, incidence rates and arteria dorsalis scapulae discount hydrochlorothiazide 25mg otc, low fatality rate means that many men new cases each year arteria latin purchase 12.5mg hydrochlorothiazide. There years in 2000 making this the most nosed neoplasm affecting men beyond mid is even a recognized increase in those Asian prevalent form of cancer in men. Thus, about three-quarters of of prostate cancer have been influenced by suggest the influence of lifestyle or environ cases worldwide occur in men aged 65 or the diagnosis of latent cancers (whose pres mental fac to rs in etiology. Dietary Certain Possible Uncertain patterns suggest that saturated fat is a sig nificant risk fac to r, while micronutrients such as the vitamins A, E and D, selenium, Age Androgens Body size lycopene and calcium may exercise a pro High fat diet Race Sexual activity tective effect against cancer. The role of hormones, especially androgens, Family his to ry Estrogens Vasec to my is obviously important, granted the impact Selenium Vitamin A of orchidec to my (excision of the testes) on progression. However, an endocrine basis Vitamin E/D Calcium for carcinogenesis is still not well under s to od. Genetic polymorphisms in the andro Phy to -estrogens Lycopene gen recep to r may be more important than Table 5. Studies of body size, vasec to my, sexu al activity and cigarette smoking as risk fac the distribution of mortality rates is less than in whites, who in turn have rates con to rs have produced inconclusive, equivocal affected than incidence by the effects of siderably higher than populations of Asian results. A diet characteristic of Asian countries such (whether through screening, or by detec as Japan and China, essentially a low fat tion of latent cancer in tissue removed dur Etiology intake with consequent low body weight, ing prostatec to my operations). Mortality Age is the strongest risk fac to r for prostate with an intake of relatively high levels of rates are comparatively high in North cancer. Development of this malignancy is a phy to -estrogens (Box: Phy to -estrogens, America, Northern and Western Europe, multi-step process associated with a long p78) may provide the means of restraining Australia/New Zealand, parts of South natural his to ry [2]. It can be inferred that the growth and progression of prostate can America (Brazil) and the Caribbean, and in the initiation of preneoplastic lesions and cer. A strategy for prevention would be to much of sub-Saharan Africa and low in microscopic cancer is influenced by envi increase the intake of phy to -estrogens, Asian populations, and in North Africa (Fig. The difference in mortality between case for lifestyle causes and primary pre bly certain flavonoids [3]. Racially Although many of the risk fac to rs for ade for prostate cancer may be less than for based differences are evident within the nocarcinoma of the prostate (Table 5. Although mortality rates increased generally in the last 30 years, in some places. Microfocal, latent or incidental induration are indicative of prostate can prostate cancer are terms used to cer. Good clinical directed attention to the relatively high practice requires that symp to matic incidence of these microscopic cancers patients need a differential diagnosis before the age of 50. Transrectal Slow growth with long doubling times, as ultrasound guided biopsies establish the well as de-differentiation over time, even dimensions of the prostate gland and in the advanced stages of the disease, enable effective location of the usual six are the hallmarks of prostate cancer [3]. Radiolabelled immunoproteins may well familial genetic susceptibility loci have offer a potential imaging improvement. Detection Pathology and genetics Prostate cancer is genetically unstable the presence of lower urinary tract symp Cancer of the prostate is a slow but con and its genomic mutations can be divid to ms. Tumour growth suppressor tal organs and give rise to distant metas generally attains its peak incidence in proteins such as p53 and bcl-2 are cur tases, particularly to the bones. Prostatic intraep rently being evaluated as prognostic fac rectal examination is the simplest way to ithelial neoplasia (Fig. Less common testicular curable prostate cancer versus the differentiation or grade of the tumour is a tumours are Leydig cell tumours, Ser to li advanced incurable disease has provoked well-recognized dominant prognostic fac to r tumours, rhabdomyosarcoma and, in the heated controversies regarding the impact that predicts the outcome of disease in all elderly, non-Hodgkin lymphoma. The Gleason grade scoring system Epidemiology a reasonable life expectancy, cure is the is now widely accepted as a means to Cancer of the testis accounts for 1. Radical prostatec to my assess the his to logical degree of differenti male cancers in most markedly affected (retropubic, perineal or laparoscopic) is ation. A rapid increase in incidence has Although the cure rate is very high, side kallikreins, microvessel density, epidermal been observed in most countries, such that effects may include incontinence (2-10%) growth fac to rs and androgen recep to rs. Due to subse Tuning or integrating the different prognos most common malignancy among young quent incapacity to produce semen, men tic fac to rs in to a nomogram, or an analysis men at age 15-34. The reasons for this who wish to father children may be advised by artificial neural net system may provide trend are not well unders to od, although concerning sperm-banking or retrieval. The highest incidence commended for patients who are not suit Survival time after diagnosis is significantly is in Central Europe (Denmark, Norway and able for surgery. Locally advanced dis including Japan, with only Israel having an ease is frequently managed by a combina intermediate rate. Such endocrine Definition fourth decades of life and declining after treatment may comprise luteinizing hor the most common malignant tumours of age 50; the median age at diagnosis for mone-releasing hormone agonists, anti the testis (>90%) are germ cell tumours, testicular nonseminoma is 24 years and a androgens or orchidec to my. The initial choice of treatment is best done after counselling the patient and with access to a multidisciplinary team. Endocrine treat ment almost invariably achieves a remis sion of the disease for a period, followed by a relapse and the development of endocrine unresponsive cancer. This type of disease needs aggressive but compas sionate management, depending upon the general health status of the patient. More research is, however, essential to establish specific optimal treatment for the individual patient. Stage and grade determine the outcome of the disease in both localized and advanced disease. The limiting fac to r to cure is the presence of extraprostatic extension of the < 0. Incidence has increased significantly while mortality has decreased, due to effective chemotherapy. Germ cell tumours can also arise of testicular cancer have not been estab tion, ultrasonography and biopsy. There is an increased incidence of patients with nonseminoma, serum Ovarian germ cell tumours of young the disease in individuals with a his to ry of tumour markers alpha-fe to protein and/or women share clinical features and treat an undescended testicle, testicular femi human chorionic gonadotrophin are elevat ment approaches with male germ cell nization and those with a family his to ry of ed in 80% of patients with disseminated tumours. In utero exposure to disease and in 50% of patients with early monly associated with the presence of exogenous estrogens may increase the stage disease. Patients with testicular isochromosome 12p (an abnormal chro risk of testicular cancer as a result of seminoma may have modestly elevated mosome 12 with two identical short increased incidence of cryp to rchidism and levels of human chorionic gonadotrophin arms), a region which contains the gene dysgenesis. The initiation of a to diethylstilbestrol has been associated There are no reliable screening tests for germ cell tumour is associated with var with an increased relative risk of up to 5. Testicular cancer is more common in a high cure rate, advocacy of testicular mental pathway of the germ cell (Fig. About 90% of testicular malignancies tumours should yield average cure rates in arise from germ cells and these tumours excess of 95%, and even 80% of patients Detection are classified as seminoma (40%) (Fig. The division of a precursor cell, the sperma to cyte (4n), produces 4 sperm cells each with one set of chromosomes (1n). The fusion of egg and sperm to form the zygote doubles the number of chromosomes to the normal complement (2n). Aberrant deve lopment may produce a cell which has twice the normal chromosomal complement (4n). Approximately 30% Stage I disease, confined to the testis, is Nonseminoma of patients under surveillance will relapse managed by post-operative radiotherapy Patients with local nonseminoma confined and are reliably cured with chemotherapy. Good to neal lymph node dissection and are Cancers of the male reproductive tract 213 found to have positive nodes can consider Patients with nonseminoma who have nor two cycles of adjuvant chemotherapy malized serum tumour markers and resid (100% cure rate). Note the high incidence rates in Central and South America, Southern Africa and India. These changes are most rates are observed in China, and in evident for adenocarcinomas, which share Definition Western Asia. In developed countries, the to some extent the etiological agents of the majority of epithelial tumours of the incidence rates are generally low, with age squamous cell carcinomas, but for which cervix are squamous cell carcinomas standardized rates of less than 15 per cy to logical screening is ineffective in coun (85%). Adenocarcinomas are less com 100,000, with the exception of Eastern tering the increase in risk. Most cervical carcinomas arise at Europe, where incidence rates range from countries the situation is more mixed, with the junction between the columnar epithe 18-35 per 100,000. The incidence of can high rates persisting in some areas (Latin lium of the endocervix and the squamous cer of the cervix begins to rise at ages 20 America, India, Africa), and declines else epithelium of the ec to cervix, a site of con 29, and then increases rapidly to reach a where, most notably in China. Only this requirement has revealed that high when invasive disease is established do parity, smoking and long-term use of oral symp to ms such as vaginal bleeding, dis contraceptives are co-fac to rs that increase charge and pain become manifest. The assessment of the biopsy or hysterec to my specimen patholo under the normal squamous epithelium of the exo role of these co-fac to rs requires that the gy. One of the precursors to logy may ablate an undetected adeno of invasive adenocarcinoma is recognized carcinoma in situ or microinvasive carcino as adenocarcinoma in situ. Recurrences or persistent resid times difficult to diagnose, often not being ual disease may occur. For early stage invasive carcinoma, where Squamous cell carcinomas may be either the cancer is confined to the cervix or large cell non-keratinizing or large cell ker spread to the upper vagina, surgery and atinizing, or a less common variant, such radiotherapy are the primary treatment as the well-differentiated verrucous carci options. The worldwide prevalence of adeno for patients with advanced disease and carcinomas of the cervix has increased external beam therapy is used initially for from 5% in 1950-60 to 20-25% of all cervi patients with bulky tumours. The most common type is intracavity radium source is being replaced mucinous adenocarcinoma, which may be with caesium-137, which is considered intestinal, endocervical or signet-ring, fol safer. The observation that cancer may still recur, or residual disease the pelvic wall veins and lymphatics [6]. Cancers of the female reproductive tract 217 estrogen therapy for menopause or prior oophorec to my, increase the risk of cancer whereas oral contraceptives containing an estrogen-progesterone combination decrease it. Syndromes of increased endogenous estrogen exposure, such as granulosa-theca cell tumours of ovary and polycystic ovary, are also associated with an increased risk. Detection the most common sign is metrorragia (uterine bleeding), especially after menopause. Low rates occur in echography and hysteroscopy are useful common cancer of women with 189,000 Africa and Asia (Fig. Canada, are experiencing a clear decline in incidence and mortality from cancer of the Pathology and genetics uterus, particularly among young women. Uterine can this tumour type is characterized by the cer occurs primarily in elderly women, the disappearance of stroma between abnor median age of onset being around 60 years old; only 5% of cases develop before age 40. Etiology Cancer of the endometrium is linked to reproductive life with increased risk among nulliparous women and women undergoing late menopause (Reproductive fac to rs and hormones, p76). The endometrium is normally a hormonally responsive tissue, responding to estrogens with growth and glandular proliferation and Fig. Post ings in to the lumens, disordered nuclear endometrial tumorigenesis is becoming operative radiation therapy is currently chromatin distribution, nuclear enlarge characterized (Fig. Patients with given to patients at a high risk of relapse ment, a variable degree of mi to sis and is lesions which are positive for cy to plasmic following surgery. In inoperable cases, associated with necrosis and haemorrhage estrogen and progesterone recep to rs have pelvic radiation therapy, usually external [16]. Adenosquamous carcinoma, which a better rate of disease-free survival than beam and intracavity irradiation, may be comprises 7% or less of cases, has a poor those with no identifiable recep to rs [16]. An enhanced sus herin are associated with metastasis and cisplatin, doxorubicin and cyclophos ceptibility to endometrial cancer has also depth of myometrial invasion. Estrogen and perimenopausal women and are estro abdominal hysterec to my and bilateral salp replacement therapy is recommended gen-related, with hyperplasia ante cedent ingo-oophorec to my (removal of the fallopi initially only in patients with in situ dis (adenoma to us and atypical adenoma to us an tubes and ovaries) are the definitive ease or with low risk stage I tumours. More 75-85% and for localized disease up to appear in postmenopausal women tend to than 50% of recurrences occur in the first 90% (Fig. Thus regular and evidence to suggest that black women Cancers of the female reproductive tract 219 Fig. Pelvic ultra slightly increased with nulliparity and a per sonography, tumour markers and clinical Definition sonal his to ry of breast cancer. Decreased examination have proved ineffective in mass the majority of ovarian cancers are carci risk follows the use of oral contraceptives. In screening [7] and are employed only for nomas, which arise from the surface contrast, hormonal treatment for infertility patients having a high familial risk of ovarian epithelium of the ovary. The comparison of molecular profiles at the menopause is only associated with a generated by laser capture microdissection Epidemiology small risk. Early menarche or late is hoped to identify patterns of proteins About 190,000 new cases and 114,000 menopause may also entail a slightly which are uniquely expressed in early dis deaths from ovarian cancer are estimated increased risk [18]. Diet plays a role, with ease in order to generate valuable markers to occur annually. The highest rates are increased risk linked to obesity and height, as for early detection [20]. Low rates A his to ry of pelvic inflamma to ry disease, Pathology and genetics are found in Africa and Asia (Fig. Detection lial tumours, including germ cell tumours, the great majority of patients with epithelial gonadal-stromal tumours and tumours which Etiology ovarian cancer present with disease that has have metastasized to the ovary, are less com Although most ovarian cancers are sporadic, spread outside of the ovary and even the mon. Three categories of lesions are recog a family his to ry is the single most important pelvis [19]. Symp to ms may include abdomi nized: benign, low malignancy potential or 220 Human cancers by organ site invasive malignant. The reasons for such differences undergo screening for breast, cervical and recorded with reference to national or oth are likely to be complex and multifac to rial. Such differences involv den is rarely distributed uniformly across Environmental/behavioural fac to rs may dif ing increased incidence provide an oppor such groupings. A number of variables may contribute quantities of red meat, large quantities of affected by ethnic and social differences. One such variable, fruit and vegetables) may be protective in For example, the way that pain is per genetic make-up, is not amenable to inter relation to risk of colorectal cancer, but risk ceived and dealt with is influenced by the vention but nonetheless may have an increases with the adoption of a Western ethnocultural background of the patient impact. Ethical dilemmas can develop in cer risk, with high rates of incidence in multicultural settings due to differing cul African-Americans, which may be partly Timely visits to a medical practitioner and tural beliefs and practices. More research related to genetic differences in hormone participation in screening programmes are in to the relationship between ethnicity metabolism (Farkas A et al. Language may be a barrier to support, survival, and quality of life is confer susceptibility to cancer may be car understanding health issues. Recognition of multicultural issues is this may be partly attributable to the novel becoming more widespread. Women of lower Networks for Cancer Awareness Research than that of the general population. In Cancers of the female reproductive tract 221 early disease includes bilateral salpingo ed with vincristine, actinomycin and oophorec to my and to tal abdominal hys cyclophosphamide; cisplatin, vinblastine terec to my, to tal omentec to my, appendec and bleomycin; or cisplatin, e to poside and to my, collecting samples of peri to neal bleomycin. Recurrent ovarian cancer may washings for cy to logical analysis and pos be treated with cy to reductive surgery plus sibly removal of pelvic retroperi to neal and chemotherapy and palliative radiotherapy. Reproductive function Hormonal therapy may include progesta and fertility may be conserved in patients tional agents and anti-estrogens. Aneuploidy has therapy may play a limited role in selected been linked to poor survival. A standard chemotherapy for advanced five-year survival rates for all stages com stage ovarian cancer using cisplatin and bined (Fig. Most Management paclitaxel achieves response rates of up to women, however, present with late stage Surgery is most often the first recourse in 60-80%. Germ cell tumours are very sen disease which is associated with a five diagnosis and treatment. Treatment of sitive to chemotherapy and may be treat year survival rate of about 20%. Esteller M, Xercavins J, Reven to s J (1999) Advances in Kearsley J, Williams C eds, Cancer: a comprehensive clinical the molecular genetics of endometrial cancer. High incidence rates occur in Northern Iran, the survival rates are less than 15%. Central Asian republics, North-Central China, parts of South America and in Southern and Eastern Africa. However, in particular areas, oesophageal cancer in distinct geograph such as Normandy and Brittany in France ical areas are more extreme than and in the north-east of Italy, the inci Definition observed for any other cancer. Regions dence rates are much higher in males (up the great majority of oesophageal can of high incidence of squamous cell carci to 30 per 100,000), while remaining rela cers (over 95%) are either squamous cell noma in Asia [1] stretch from the tively low in females. Other incidence of all oesophageal cancers Cancers of the oesophagus are the sixth high-incidence areas are found in parts vary greatly (Fig. In of South America and in Southern and 2000, the number of deaths due to Eastern Africa. Even within these high Etiology oesophageal cancer amounted to some risk areas, there are striking local varia Consumption of to bacco and alcohol, 337,500 out of a to tal of 6. Studies of migrant popula associated with low intake of fresh fruit, cer deaths worldwide. About 412,000 tions suggest that when they move to vegetables and meat, is causally associat cases of cancer of the oesophagus occur areas of low-risk, they lose their high ed with squamous cell carcinoma of the each year, of which over 80% are in devel rates, confirming the importance of local oesophagus worldwide. In more developed countries, it is esti Oesophageal cancer 223 being the outcome of chronic mucosal the vast majority of patients initially injury. Other risk fac to rs include con complain of progressive dysphagia, sumption of pickled vegetables, betel which may not become apparent until chewing in South East Asia, and oral con some two-thirds of the lumen has been sumption of opium by-products in the obstructed, especially in the case of Caspian Sea area. Regur have proposed a role for human papillo gitation and pain on swallowing are fre maviruses in squamous cell carcinoma quent, as is weight loss. Other environmental risk fac to rs involvement may be indicated by hoarse include nitrosamines, food contamination ness. Patients with adenocarcinomas of with fungi such as Geotrichum candidum the cardia may also suffer from gastro and Fusarium sp. A barium swallow p43) and deficiency of vitamins A and C, (ingestion of liquid containing barium molybdenum, copper and zinc.
The accumulation of more and more symp to ms eventually prevented her from working or carrying out any reasonable social life blood pressure medication foot pain order hydrochlorothiazide 12.5 mg fast delivery. She knew that these were her own notions hypertension 2 symptoms best order for hydrochlorothiazide, that they were stupid heart attack questions purchase hydrochlorothiazide 12.5 mg with mastercard, but she could not s to p herself thinking and performing them heart attack survival rate cheap hydrochlorothiazide 25 mg without a prescription. The compulsive behaviour often provokes further anxiety in the patient heart attack karaoke demi lovato order generic hydrochlorothiazide line, the need both to perform the action and to preserve social acceptability arteria tibial posterior hydrochlorothiazide 25mg cheap. Although wide areas of life are often implicated in compulsive rituals hypertension journal article cheap 12.5 mg hydrochlorothiazide otc, it is often striking how the obsessional person omits other areas from his obsessionality arrhythmia names discount 25 mg hydrochlorothiazide with visa. The patient who excoriates his hands by excessive washing and devotes a substantial portion of each day to the pursuit of cleanliness may drive to work in a dirty and ill-serviced car and work in an untidy offce! Obsession may occur as thoughts, images, impulses, ruminations or fears; compulsions as acts, rituals, behaviours. The craving of an alcoholic for his beverage or the abnormal drive of sexual deviation is not compulsive in a strict sense. The obsessions or compulsions may be more complex and ritualistic, for example a patient who tried to shut the car door after getting out found this very diffcult because he was afraid that the act of shutting would produce unpleasant, obscene, repetitive thoughts. For this reason, he had to go to elaborate lengths to put the car in a certain place, check all the doors before getting out, check them all again after getting out and turn the key while looking in a particular direction. The images of obsessional thinking may be vivid but are always known by the patient to be products of his own mind. The disruptive image may intrude while compulsive rituals are being carried out and neces sitate the ritual being recommenced. Ruminations are often pseudophilosophical, irritatingly unnecessary, repetitive and achieve no conclusion. Reassurance that he will not harm himself or others or act on the impulses can be given to the obsessional, provided it is truly obsessional in form, that he is not concurrently depressed and that there is not coexist ing dissocial personality disorder. The constituent elements of obsessive-compulsive experience are said to include: 1. Obsessions occur in the context of obsessive-compulsive disorder as the major symp to m of the condition. The depressed patient with obsessional (anankastic) personality may show obsessions and compulsions that clear when his illness is treated. Obsessional symp to ms may occur in schizophrenia, when they usually have a bizarre character. Apparent obsessional symp to ms may arise de novo in an older person, associated with an organic psychosyndrome. However, the element of resistance characteristic of obsessionality is usually not present. It seems that the person carries out repetitive behaviour in order to cope with the uncertainties of his life caused by his failing memory and performance. Repetition and stereotyped behaviour in those with learning disability has sometimes been labelled compulsive; however, this is psychopathologically incorrect, as there is no resistance or confict of urge and repulsion. Similarly, repetitiveness and stickiness of thinking occur with epilepsy, following head injury and with other organic states, but again, this is not truly obsessional in nature. There is a striking similarity between the clinical presentation of obsessive-compulsive dis order in children and adolescents and in adults (Swedo et al. In 70 consecutive juvenile patients, washing and grooming, repeating, checking and to uching rituals were the most frequent compulsions, and obsessions were contamination fears, concerns about disasters happening to the patient or those close to him, symmetry and scrupulousness. Although the condition was frequently familial, the actual presenting symp to ms were not shared by relatives, even by monozy gotic twins. There is some evidence that there are categories of obsessive-compulsive fears and behaviours that are associated with particular types of threat, or threat domains. The role of disgust in the psychopathology of anxiety disorders, and principally in obsessions and compulsions is gradually being examined and unders to od. Disgust can be considered as an adaptive system that evolved to motivate disease-avoidant behaviours. It is argued that it arose to facilitate the recognition of objects and situations associated with risk of disease and to drive hygienic behaviour. Furthermore, disgust assumed a role in regulating social behaviour by acting to mark prohibited and disapproved behaviours as unacceptable. In this regard, disgust can be conceptualized as a strong and visceral emotion that can arouse powerful affective and behavioural responses. Obsessions and compulsions can be unders to od in this schema as disorders of disgust systems: patients present with contamination fears, suffer from intrusive thoughts of contamina tion, engage in excessive sanitation and disinfection of self and the environment (for a fuller exploration and discussion of the place of disgust in psychopathology see Curtis, 2011). Bunyan J (1666) Grace Abounding to the Chief of Sinners: or, a Brief and Faithful Relation of the Exceeding Mercy of God in Christ, to his Poor Servant John Bunyan (ed. With All the Kinds, Causes, Symp to mes, Prognostickes, and Several Cures of it by Democritus Junior. The Weekly Magazine of Original Essays, Fugitive Pieces, and Interesting Intelligence, Philadelphia. Tarrier N and Turpin G (1992) Psychosocial fac to rs, arousal and schizophrenic relapse. This page intentionally left blank C H A P T E R 18 Disorders of Volition and Execution Summary In this chapter, the experience of contentless non-directional urge; natural instinctual drive directed to wards some target and the volitional act with a consciously conceived goal and an awareness of how to achieve it and its consequences are discussed. Abnormalities of urge, instinct, drive and will are some of the most complex in psychopathology. Need is a striving to wards a particular object, state or action that is experienced as a desire. Will is a goal-directed striving or intention based on cognitively planned motivation. For I know that in me (that is, in my fesh,) dwelleth no good thing; for to will is present with me; but how to perform that which is good I fnd not. Now if I do that I would not, it is no more I that do it, but sin that dwelleth in me. I fnd then a law, that, when I would do good, evil is present with me But I see another law in my members, warring against the law of my mind, and bringing me in to captivity to the law of sin which is in my members. The Epistle of Paul the Apostle to the Romans (1662) this is the most unsatisfac to ry subject area in clinical psychopathology. The dissatisfaction derives partly from the loss of interest in the subject since the end of the nineteenth century and the lack of conceptual clarity that has resulted from the impoverished literature but also because of the inherent complexity of the subject. The distinctions between related but distinct concepts such as instinct, urge, impetus, impulse, drive, motivation, will, involuntary and voluntary movements and responsibility have until very recently ceased to be regarded as proper subjects of inquiry. A distinction can correctly but theoretically be drawn between the instinct and thus desire to carry out an action in order to satisfy a particular need, the drive and motivation to effect the action and the will to execute the action. All these are different from the end product, the observable action or behaviour itself (Figure 18. Urge, Drive and Will, and Their Disturbance Jaspers (1959) distinguishes between the different experiences of primary, contentless non directional urge; natural instinctual drive directed to wards some target; and the volitional act with a consciously conceived goal and an awareness of how to achieve it and its consequences. Thus, for Jaspers, there is a distinction, subjectively, between impulsive acts, awareness of inhibition of will and awareness of loss of will or availability of will-power. Scharfetter then describes those primary needs that are innate and not learned as hunger, thirst, breathing, urination and defecation, sleep and self-preservation. Other needs are not essential for survival; their demands can be postponed and they are more affected by acquired patterns of behaviour, such as sexual need and prosocial need. While I write this, I allow myself to become aware of the primary need for breathing, but I shall not be giving it a thought ten minutes from now. The acquired primary needs and secondary needs have a greater infuence on the individual mental state than innate primary needs. In this view, it can either activate or determine selectivity or strength of actions. Hull (1943) introduced the concept of need as a preliminary to introducing the more mechanical concept of drive. The function of the effec to r apparatus is to mediate the satiation of these needs. In other words, it includes the pleasurable rewards that govern and regulate behaviour as well as the reasons proffered for behaviour. Intrinsic fac to rs are those that are internal to the person, and extrinsic fac to rs are those, such as supermarket reward cards, that are external incentives to behave in particular ways. Thus, the term motivation refers not only to the goal to wards which behaviour is directed but also to emotional states that set it off as well as those that act to reward the behaviour. Similarly, will is a necessary concept but we have great diffculty in comprehending it. And therefore our exertions, our deliberations, our purposes, our promises, are only in things that depend upon our will. Our advices, exhortations, and commands, are only in things that depend upon the will of those to whom they are addressed. Hence, theories of will have implications for notions of moral responsibility, for what being an agent entails and for any description of guilt, shame and punishment. There are more modern attempts to clarify and delineate the phenomenology of will. To amplify these points, Bayne and Levy (2006) write: We typically experience our actions as purposive. We do not simply fnd ourselves walking to wards a door and, on the basis of this, form the belief that we must be intending to open it; instead, we experience ourselves as walking to wards the door in order to open it. For example, one might experience oneself: walking to wards a door in order to open it; opening the door in order to feed the dog; and feeding the dog in order to keep him quiet. The phenomenology of a single action can include the nested purposes for which the action is being performed. The range of defnitions and understandings of the various terms underlines the intrinsic complexity of the subject area and the current absence of a unifying theory or model for making sense of the subject. There may be a disturbance of need, which may involve hunger, thirst, explora to ry behaviour or sleep. Abnormality of thirst can take the form of increased thirst in lithium-induced polydipsia (diabetes insipidus) or of compulsive water drinking in psychosis (Singh et al. Abnormality of explora to ry behaviour can take the form of diminution, which is manifest as lack of curiosity and exploration of the environment. There are different patterns of insomnia, including initial insomnia, which is more often associated with anxiety-based disorders, and early morning wakening, which is characteristic of depression. Diminution of drive to wards primary needs occurs in schizophrenia and depression, and is probably indistinguishable from abnormalities of need. It is manifest as an absence of the activating tension that initiates behaviour and is observable as apathy. If drive determines strength and selectivity of goal of behaviour, then perversion of drive will include such conditions as fetishism. In schizophrenia and depression, the pleasurable intrinsic motivation that acts as incentive for behaviour may be lost. This is most accurately described as anhedonia, the absence of pleasure in relation to usually pleasurable activities. In mania, it may be increased so that mundane activities become unduly fascinating and rewarding. Disorder of motivation can also be unders to od as involving the abnor malities of reasoning, justifcation and explanation, as described in the psychoanalytical literature. As Jeannerod (2006) put it, disorder of volition should only refer to those pathological conditions in which the ability to make choices, to express preferences, or possibly to experience pleasure and freedom in making these choices or expressing these preferences is affected. This can take the form of impairment of the will to act in schizophrenia and severe depression. The observable end result is lack of action in the absence of any mo to r abnormality impairing action. Other abnormalities of will include indecisiveness in depression, ambivalence or ambitendency in schizophrenia. These abnormalities have, at their core, contrast ing conceived goals with oscillating decision making that is observable as indecision or alternating and contrasted mo to r behaviours. Failure of volition as a result of inability to experience pleasure, that is, as a result of anhedonia has been discussed elsewhere (Chapter 16). Localized disease in this area, of either a structural or biochemical nature, is therefore likely to result in disturbance of drive and hence volition. Excessive appetite (bulimia) may occur with conditions such as tumour affecting the hypotha lamus and result in gross obesity, obesity may be associated with hypoventilation and excessive sleeping (hypersomnia) in the Pickwickian syndrome (Burwell et al. Excessive thirst and fuid intake (polydipsia) occur with disease of the posterior pituitary or the kidney (nephrogenic diabetes insipidus, for example, with lithium treatment). Loss of appetite (anorexia) may occur with localized disease of the midbrain, resulting in severe cachexia; however, weight loss is much more common as a general feature of any severe debilitating physical illness. There may be abnormality of appetite with polyphagia and consequent obesity, as occurs in some chronic schizophrenic patients; however, this is not usual. The more conspicuous disturbance, however, is loss of volition that results in withdrawal from normal social interaction, for instance lack of motivation to obtain and continue in employment or diminished sexual drive resulting in decreased fecundity, espe cially in male schizophrenic patients. This symp to m was described by Bleuler (1911) as disturbance of initiative, according to Lehmann (1967). It is also recognized among the so called negative symp to ms of what Crow (1980) has designated type 2 schizophrenia. Although positive symp to ms, such as delusions, hallucinations and thought disorder, are more conspicuous, especially in the earlier stages of a schizophrenic illness, the prognosis is probably affected to a greater extent by the loss of volition. Andreasen has developed an instrument for measuring the negative symp to ms of schizophre nia, the Scale for the Assessment of Negative Systems (Andreasen 1982, 1989).
Prevention or Delay of Type 2 Diabetes Treatment Goals Lifestyle Interventions Lifestyle Management Pharmacologic Interventions Pharmacologic Therapy Prevention of Cardiovascular Disease Treatment in Skilled Nursing Facilities Diabetes Self-management Education and Support and Nursing Homes End-of-Life Care S34 4 digital blood pressure monitor buy discount hydrochlorothiazide on line. Children and Adolescents Assessment of Comorbidities Type 1 Diabetes Patient-Centered Collaborative Care Type 2 Diabetes Comprehensive Medical Evaluation Transition From Pediatric to Adult Care Assessment of Comorbidities S165 14 arteria maxilar hydrochlorothiazide 25 mg overnight delivery. Lifestyle Management Diabetes in Pregnancy Diabetes Self-management Education and Support Preconception Counseling Nutrition Therapy Glycemic Targets in Pregnancy Physical Activity Management of Gestational Diabetes Mellitus Smoking Cessation: Tobacco and e-Cigarettes Management of Preexisting Type 1 Diabetes Psychosocial Issues and Type 2 Diabetes in Pregnancy S61 6 prehypertension 20s hydrochlorothiazide 12.5 mg with mastercard. Glycemic Targets Pregnancy and Drug Considerations Postpartum Care Assessment of Glycemic Control A1C Goals S173 15 blood pressure chart for 60 year old female purchase hydrochlorothiazide 12.5 mg without a prescription. Diabetes Care in the Hospital Hypoglycemia Hospital Care Delivery Standards Intercurrent Illness Glycemic Targets in Hospitalized Patients Bedside Blood Glucose Moni to ring S71 7 blood pressure 35 weeks pregnant order hydrochlorothiazide 12.5mg with visa. Diabetes Technology Antihyperglycemic Agents in Hospitalized Patients Insulin Delivery Hypoglycemia Self-moni to ring of Blood Glucose Medical Nutrition Therapy in the Hospital Continuous Glucose Moni to rs Self-management in the Hospital Au to mated Insulin Delivery Standards for Special Situations Transition From the Acute Care Setting S81 8 blood pressure 300 150 purchase generic hydrochlorothiazide from india. Obesity Management for the Treatment of Type 2 Preventing Admissions and Readmissions Diabetes Assessment S182 16 blood pressure empty chart cheap hydrochlorothiazide uk. Diabetes Advocacy Diet blood pressure chart metric hydrochlorothiazide 12.5mg with visa, Physical Activity, and Behavioral Therapy Advocacy Statements Pharmacotherapy Medical Devices for Weight Loss S184 Disclosures Metabolic Surgery S187 Index this issue is freely accessible online at care. Diabetes Care Volume 42, Supplement 1, January 2019 S1 Introduction: Standards of edical C are in iabetes 2019 Diabetes Care 2019;42(Suppl. 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. Expert opinion trials that are adequately powered, including E is a separate category for recommen c Evidence from a well-conducted multicenter trial dations in which there is no evidence c Evidence from a meta-analysis that incorporated quality ratings in the analysis from clinical trials, in which clinical trials Compelling nonexperimental evidence, i. Recommenda Supportive evidence from well-conducted randomized controlled trials that tions with an A rating are based on large are adequately powered, including well-designed clinical trials or well-done c Evidence from a well-conducted trial at one or more institutions meta-analyses. Generally, these recom c Evidence from a meta-analysis that incorporated quality ratings in the mendations have the best chance of analysis improving outcomes when applied to B Supportive evidence from well-conducted cohort studies the population to which they are ap c Evidence from a well-conducted prospective cohort study or registry propriate. Recommendations with lower c Evidence from a well-conducted meta-analysis of cohort studies levels of evidence may be equally im Supportive evidence from a well-conducted case-control study portant but are not as well supported. C Supportive evidence from poorly controlled or uncontrolled studies Of course, evidence is only one com c Evidencefromrandomizedclinicaltrialswithoneormoremajororthree ponent of clinical decision making. Clini or more minor methodological fiaws that could invalidate the results cians care for patients, not populations; c Evidencefromobservationalstudieswithhighpotentialforbias(suchas case series with comparison with his to rical controls) guidelines must always be interpreted c Evidence from case series or case reports with the individual patient in mind. The category may also example, although there is excellent when clinicians, scientists, regula to rs, include task force and expert committee evidence from clinical trials supporting and/or policy makers desire guidance reports. Cost-effectivenessofinterventions to A scientific review is a balanced review 2014 Standards of Care for the first prevent and control diabetes mellitus: a sys and analysis of the literature on a scien time having the majority of bulleted tematic review. S4 Diabetes Care Volume 42, Supplement 1, January 2019 Sum m ary of evisions: Standards of edical are in iabetes 2019 Diabetes Care 2019;42(Suppl. This section was moved (previously it was was changed (from Section 5 to Section 3) A recommendation was added to in Section 5) and is now located before the to follow a more logical progression. Lifestyle Management section to better clude the 10-year atherosclerotic cardio Although levels of evidence for several refiect the progression of type 2 diabetes. Changes in evidence type 2 diabetes who have overweight new recommendation regarding when level from, for example, E to C are not or obesity. The 2019 Standards of Care Because smoking may increase the risk contains, in addition to many minor of type 2 diabetes, a section on to bacco Section 5. Lifestyle Management changes that clarify recommendations Evidence continues to suggest that there use and cessation was added. Comprehensive Medical carbohydrate, protein, and fat for all Evaluation and Assessment of people with diabetes. Cardiovascular Disease and people who are pregnant or lactat who are not using insulin was changed and Risk Management ing, who have or are at risk for disor to acknowledge that routine glucose For the first time, this section is endorsed dered eating, who have renal disease, moni to ring is of limited additional clin by the American College of Cardiology. There is not edge heart failure as an important type a one-size-fits-all eating pattern for in Section 8. Obesity Management for of cardiovascular disease in people with dividuals with diabetes, and meal plan the Treatment of Type 2 Diabetes diabetes for consideration when deter ning should be individualized. A recommendation was modified to acknowledge the benefits of tracking the blood pressure recommenda encourage people with diabetes to de weight, activity, etc. Additional discussion was added to the considering comorbidities beyond dia the recommendation and text regard physical activity section to include the ben betes when contemplating the ap ing the use of aspirin in primary pre efit of a variety of leisure-time physical ac propriateness of metabolic surgery for vention was updated with new data. To emphasize that the risks and ben effects on body weight, d)sideeffects, the recommendation on the use of efits of glycemic targets can change as e) costs, and f) patient preferences. This new section includes new recommen A new section was added on insulin the gastroparesis section includes a dations, the self-moni to ring of blood glu injection technique, emphasizing the im discussion of a few additional treatment cose section formerly included in Section portance of technique for appropriate modalities. Annual S6 Summary of Revisions Diabetes Care Volume 42, Supplement 1, January 2019 examinations remain recommended for screening in youth with type 1 diabetes Greater emphasis has been placed on everyone. Older Adults mendation was added discouraging gestational diabetes mellitus as it does A new section and recommendation on e-cigarette use in youth. A new figure sections and/or recommendations for Because of their ability to improve hos was added (Fig. A new table was also cents were added for glycemic targets, a new recommendation was added call added (Table 12. Management of Diabetes thisstatementcompiled public informa from adult diabetes, and that there in Pregnancy tion and convened a series of meetings are also differences in recommended Women with preexisting diabetes are with stakeholders throughout the in care for children and adolescents with now recommended to have their care sulin supply chain to learn how each type 1 as opposed to type 2 diabetes. Diabetes Care Volume 42, Supplement 1, January 2019 S7 American Diabetes Association 1. Im proving are and Prom oting H ealth in Populations: Standards of edical are in iabetes 2019 Diabetes Care 2019;42(Suppl. Improving care and promoting health providers are to ols that can ultimately improve health across populations; however, in populations: Standards of Medical Care in for optimal outcomes, diabetes care must also be individualized for each patient. More infor needs, and values and that ensures that patient values guide all clinical decisions (2). S8 Improving Care and Promoting Health Diabetes Care Volume 42, Supplement 1, January 2019 intended to guide an overall approach to health strategies are needed in order to suboptimal (3). However, a gies (7,17,18); tracking medication nizing that one size does not fit all, the major barrier to optimal care is a delivery taking behavior at a systems level (19); standards presented here provide guid system that is often fragmented, lacks redesigning the organization of the care ance for when and how to adapt rec clinical information capabilities, dupli process (20); implementing electronic ommendations for an individual. This has been accompanied approach) moreeffectivehealthcaredeliverysystems by improvements in cardiovascular out 2. Decision support (basing care on the care team, which centers around ductions in end-stage microvascular evidence-based, effective care the patient, should avoid therapeutic complications. Collaborative, multidisciplinary soliciting performance feedback, setting tent variability in the quality of diabetes teams are best suited to provide care reminders, and providing structured care care across providers and practice set for people with chronic conditions such. It is Strategies for System-Level Improvement macists, and other providers (17,38). After adjusting for infiation, ing in an environment where patient ing new opportunities for team-based economic costs of diabetes increased centered high-quality care is a priority chronic disease management (39). While many diabetes pro Telemedicine is a growing field that attributed to the increased prevalence cesses of care have improved nationally may increase access to care for patients of diabetes and the increased cost per in the past decade, the overall quality of with diabetes. Ongoing population care for patients with diabetes remains as the use of telecommunications to care. A growing body of evidence sug agree on a targeted approach for a spe gests that various telemedicine modali cific barrier (12). For rural populations or those sis on the protection of people with context, including potential with limited physical access to health preexisting conditions, health promotion, food insecurity, housing stabil care, telemedicine has a growing body of anddiseaseprevention(45). Infact,health ity, and financial barriers, and evidenceforits effectiveness, particularly insurance coverage increased from apply that information to treat with regard to glycemic control as mea 84. There is limited data avail by the Affordable Care Act, the Agency when available. A able on the cost-effectiveness of these for Healthcare Research and Quality strategies. Information and guid social and environmental fac to rs and the solving), and engagement with psycho ance specific to quality improvement and prevention and treatment of diabetes social concerns (26). Critical to these be drawn upon to inform systems-level in a given time period divided by the efforts is provider adherence to clinical strategies in diabetes. For example, the number of pills prescribed by the physi practice recommendations and accu National Academy of Medicine has cian in that same time period) (19). Success in overcoming metabolic goals (56) and incentives that cussed in the clinical encounter (61). A S10 Improving Care and Promoting Health Diabetes Care Volume 42, Supplement 1, January 2019 study by Piette et al. Creating systems-level following the administration of sul are receiving increasing attention from mechanisms to screen for social deter fonylureas or insulin. Providers should con dations for lifestyle modification in real ing to ols for some social determinants of sider these fac to rs when making treat world settings (77). Below is a discussion of assess members to more regularly obtain particularly in underserved communi ment and treatment considerations in nutritious food (74). Additionally, patients with diabe diovascular risk fac to rs in underserved 14% (or one of every seven people) tes who are homeless need secure places communities and health care systems of the U. The rate is higher in some racial/ethnic frigera to r access to properly s to re their minority groups, including African insulin and take it on a regular schedule. American and Latino populations, in References Risk for homelessness can be ascertained 1. What is population low-income households, and in homes using a brief risk assessment to ol de healthfi Institute of Medicine Committee on Quality type 2 diabetes is increased twofold in veterans (75). Available from cations appropriately and recommended sources or have access to social workers. Accessed 22 Oc to ber self-care behaviors, depression, diabe that can facilitate temporary housing 2018 tes distress, and worse glycemic control for their patients as a way to improve 3. Active Language barriers, physician-patient language Twelve evidence-based principles for imple care management supported by home tele concordance, and glycemic control among in menting self-management support in primary moni to ring in veterans with type 2 diabetes: sured Latinos with diabetes: the Diabetes Study care. Health systems, patients Practice-linked online personal health records medicalhomeanddiabetes. Communityhealthambassadors:amodelfor tes: a systematic review and meta-analysis of provements following a multifaceted diabetes engaging community leaders to promote better randomized trials. How our current medical care in the care of diabetes patients: systematic review Collaborative care for patients with depression system fails people with diabetes: lack of timely, and meta-analysis. Treat self-management interventions improve glyce Riskof coronaryarterydiseaseintype2diabetes ment intensification and risk fac to r control: to mic control in medically underserved adults with and the delivery of care consistent with the ward more clinically relevant quality measures. Intensification of antihyperglycemic ther Care Act and diabetes diagnosis and care: ex Effectiveness of quality improvement strategies on apy among patients with incident diabetes: ploring the potential impacts. Curr Diab Rep the management of diabetes: a systematic review a Surveillance Prevention and Management 2016;16:27 and meta-analysis. Accessed care, and health care expendituresamong Medi Randomized trial of a literacy-sensitive, 22 Oc to ber 2018 care beneficiaries: 15 randomized trials. Accessed 22 Oc to ber 2018 S12 Improving Care and Promoting Health Diabetes Care Volume 42, Supplement 1, January 2019 53. Diabetes care and quality: ecological determinants of prediabetes and socioeconomic disparities in chronic disease. Development and validation of aninstrument care-professionals/practice-transformation/ ing, and Medicine. A Framework to Address to assess imminent risk of homelessness among defining-quality-care/diabetes-care-quality/Pages/ the Social Determinants of Health [Internet], veterans. Peer men to ring healthdisparitiesforcardiovasculardiseasesand consensus standards for ambula to ry cared and financial incentives to improve glucose associated fac to rs among American Indian and measuring healthcare disparities [Internet], 2008. Health disparities Consensus Standards for Ambula to ry Care% support of complex health behaviors in preven among youth with type 1 diabetes: a systematic E2%80%94Measuring Healthcare Disparities tion and disease management with special ref review of the current literature. World Health Organization Commission on foodinsecurityanddepression,diabetesdistress 88cc-49c3-a238-66def942c147. Closing the gap and medication adherence among low-income 22 Oc to ber 2018 in a generation: health equity through action patients with poorly-controlled diabetes. Accessed 22 Oc to ber 2018 Diabetes Care Volume 42, Supplement 1, January 2019 S13 American Diabetes Association 2. Type 2 diabetes (due to a progressive loss of b-cell insulin secretion frequently on the background of insulin resistance) 3. Type 1 diabetes and type 2 diabetes are heterogeneous diseases in which clinical Suggested citation: American Diabetes Associa presentation and disease progression may vary considerably. Classification and diagnosis of diabetes: portant for determining therapy, but some individuals cannot be clearly classified as Standards of Medical Care in Diabetesd2019. Children with type 1 Readers may use this article as long as the work is properly cited, the use is educational and not diabetes typically present with the hallmark symp to ms of polyuria/polydipsia, and for profit, and the work is not altered. S14 Classification and Diagnosis of Diabetes Diabetes Care Volume 42, Supplement 1, January 2019 classic symp to ms seen in children. Type 2 diabetes is primarily as between A1C and either glucose-based nosis becomes more obvious over sociated with insulin secre to ry defects test. Future classification A1C to rs can result in the progressive loss of schemes for diabetes will likely focus b-cell mass and/or function that mani on the pathophysiology of the underly Recommendations fests clinically as hyperglycemia. It should be noted ation of using an assay without that the persistent presence of two or that the tests do not necessarily detect interference or plasma blood glu more au to antibodies is an almost certain diabetes in the same individuals. The cose criteria to diagnose diabe predic to r of clinical hyperglycemia and efficacy of interventions for primary pre tes. Diabetes teria should be used to diagnose the paths to b-cell demise and dys may be identified anywhere along the diabetes. Food and prediabetes or type 2 diabetes in chil lower levels of 1,5-anhydrogluci to l, suggest Drug Administration approved for diag dren and adolescents. Marked dis red blood cell turnover, such as sickle cell generally applied for glucose moni to ring. For sis, recent blood loss or transfusion, or quired), greater preanalytical stability, patients with a hemoglobin variant but erythropoietin therapy, only plasma blood and less day- to -day perturbations during normal red blood cell turnover, such as glucose criteria should be used to diagnose stress and illness. A1C is less reliable than vantages may be offset by the lower assay without interference from hemo blood glucose measurement in other con sensitivity of A1C at the designated cut globin variants should be used. The A1C test, with the common hemoglobin variant HbS Confirming the Diagnosis a diagnostic threshold of $6. If using two separate test indirect measure of average blood glu zygous women compared with those samples, it is recommended that the cose levels and to take other fac to rs in to without the variant (15). Although only a minority ation of the possibility of A1C assay in of patients with type 1 diabetes fall in to terference.
