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Antiplatelet and anticoagulant drugs for prevention of restenosis/reocclusion following peripheral endovascular treatment cholesterol medication statin atorvastatin 20 mg with amex. Negative association between infrarenal aortic diameter and glycemia: the Health in Men Study cholesterol medication calculator purchase 10 mg atorvastatin free shipping. Mortality results for randomised controlled trial of early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms cholesterol medication dementia discount atorvastatin 40mg with visa. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms cholesterol lowering foods uk purchase atorvastatin 5mg on line. High prevalence of peripheral arterial disease and co-morbidity in 6880 primary care patients cholesterol medication online cheap 10mg atorvastatin. A population-based study of peripheral arterial disease prevalence with special focus on critical limb ischemia and sex differences cholesterol levels meat buy discount atorvastatin 40mg line. Ankle brachial index, C-reactive protein, and central augmentation index to identify individuals with severe atherosclerosis. High prevalence of peripheral arterial disease and low treatment rates in elderly primary care patients with diabetes. Sub-clinical vascular disease in type 2 diabetic subjects: relationship with chronic complications of diabetes and presence of cardiovascular disease risk factors. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. To coincide with World Diabetes Day in 2005, the Lancet launched an issue almost exclusively dedicated to the diabetic foot: this was the first time that any major non-specialist journal had focused on this worldwide problem; however, major challenges remain in getting across important messages relating to the diabetic foot: 1 Foot ulceration is common, affecting up to 25% of patients with diabetes during their lifetime [1]. Although it was estimated that a leg is lost to diabetes Textbook of Diabetes, 4th edition. Much progress in our understanding of the pathogenesis and management of the diabetic foot has been made over the last quarter century. This has been matched by an increasing number of publications in peer-reviewed journals. Taken as a percentage of all PubMed listed articles on diabetes, those on the diabetic foot have increased from 0. Prior to 1980, little progress had been made in the previous 100 years despite the fact that the association between gangrene and diabetes was recognized in the mid-19th century [5]. For the first 100 years following these descriptions, diabetic foot problems were considered to be predominantly vascular and complicated by infection. It was not until during the Second World War, for example, that McKeown performed the first ray excision on a patient with diabetes and osteomyelitis but good blood supply: this was performed under 727 Part 9 Other Complications of Diabetes Table 44. In the last two decades many major national and international societies were formed including diabetic foot study groups and the international working group on the diabetic foot was established in 1991. New editions of two leading international textbooks on the diabetic foot have been published in recent years [7,8], and a number of collaborative research groups are now tackling many of the outstanding problems regarding the pathogenesis and management of diabetic foot disease. In this chapter, the global term "diabetic foot" will be used to refer to a variety of pathologic conditions that might affect the feet of people with diabetes. Initially, the epidemiology and economic impact of diabetic foot disease are discussed, followed by the contributory factors that result in diabetic foot ulceration. The potential for prevention of these late sequelae of neuropathy and vascular disease are discussed, followed by a section on the management of foot ulcers. The chapter closes with a brief description of the pathogenesis and management of Charcot neuroarthropathy, an end-stage complication of diabetic neuropathy. Throughout, cross-referencing will be provided to other chapters that also cover aspects of diabetic foot disease, particularly those on diabetic neuropathy (see Chapter 38), peripheral vascular disease (see Chapter 43), bone and rheumatic disorders in diabetes (see Chapter 48) and infection (see Chapter 50). Globally, diabetic foot complications remain major medical, social and economic problems that are seen in all types of diabetes and in every country [18]; however, the reported frequencies of amputation and ulceration vary considerably as a consequence of different diagnostic criteria used as well as regional differences [19]. Diabetes remains a major cause of non-traumatic amputation across the world with rates being as much as 15 times higher than in the non-diabetic population. First, definitions as to what constitutes a foot ulcer vary and, secondly, surveys invariably include only patients with previously diagnosed diabetes, whereas in type 2 diabetes, foot problems may be the presenting feature. Third, reported foot ulcers are not always confirmed by direct examination by the investigators involved in the study. Finally, as can be seen from the table, in those studies that assess the percentage of the population that had risk factors for foot ulceration, 4070% of patients fell into that category. Such observations clearly indicate the need for all diabetes services to have a regular screening program to identify such high risk individuals. Epidemiology and economic aspects of diabetic foot disease As foot ulceration and amputation are closely inter-related in diabetes [2], they will be considered together in this section. A selection of epidemiologic data for foot ulceration and amputa- Health economics of diabetic foot disease In addition to causing substantial morbidity and even mortality, foot lesions in patients with diabetes additionally have substantial economic consequences. Moreover, few studies have estimated costs of the long-term follow-up of patients with foot ulcers or amputations [2]. Such strong economic arguments may help to drive improvements in preventative foot care which could potentially lead to significant savings for health care systems. Thus, minor injury and subsequent infection increase the demand for blood supply beyond the circulatory capacity and ischemic ulceration and the risk of amputation ensues. Etiopathogenesis of diabetic foot lesions "Coming events cast their shadow before. The words of the Scottish poet, Thomas Campbell, can usefully be applied to the breakdown of the diabetic foot. Ulceration does not occur spontaneously: rather it is the combination of causative factors that result in the development of a lesion. There are many warning signs or "shadows" that can identify those at risk before the occurrence of an ulcer. It is Diabetic neuropathy As discussed in Chapter 38, the diabetic neuropathies represent the most common form of the long-term complications of diabetes, affect different parts of the nervous system and may present with diverse clinical manifestations [27]. Most common amongst the neuropathies are chronic sensorimotor distal symmetrical Cigarette smoking dyslipidemia Peripheral vascular disease Somatic neuropathy (sensorimotor) Diabetes mellitus Autonomic neuropathy Limited joint mobility Small muscle wasting At risk neuroischemic foot Decreased pain and proprioception Increased foot pressures Decreased sweating Dry skin Callus Altered blood flow Distended foot veins: warm foot At risk neuropathic foot Trauma Psychologic/ behavioral problems Figure 44. Ischemic ulcer Neuroischemic ulcer Neuropathic ulcer 729 Part 9 Other Complications of Diabetes polyneuropathy and the autonomic neuropathies. It is the common sensorimotor neuropathy together with peripheral autonomic sympathetic neuropathy that together have an important role in the pathogenesis of ulceration. Sensorimotor neuropathy As noted in Chapter 38, this type of neuropathy is very common and it has been estimated that up to 50% of older patients with type 2 diabetes have evidence of sensory loss on clinical examination and therefore must be considered at risk of insensitive foot injury [27]. This type of neuropathy commonly results in a sensory loss confirmed on examination by a deficit in the stocking distribution to all sensory modalities: evidence of motor dysfunction in the form of small muscle wasting is also often present. While some patients may give a history (past or present) of typical neuropathic symptoms such as burning pain, stabbing pain, paresthesia with nocturnal exacerbation, others may develop sensory loss with no history of any symptoms. Other patients may have the "painful-painless" leg with spontaneous discomfort secondary to neuropathic symptoms but who on examination have both small and large fiber sensory deficits: such patients are at great risk of painless injury to their feet. From the above it should be clear that a spectrum of symptomatic severity may be present with some patients experiencing severe pain and at the other end of the spectrum, patients who have no spontaneous symptoms but both groups may have significant sensory loss. The most challenging patients are those who develop sensory loss with no symptoms because it is often difficult to convince them that they are at risk of foot ulceration as they feel no discomfort, and motivation to perform regular foot self-care is difficult. The important message is that neuropathic symptoms correlate poorly with sensory loss, and their absence must never be equated with lack of foot ulcer risk. Thus, assessment of foot ulcer risk must always include a careful foot examination after removal of shoes and socks, whatever the neuropathic history [27]. The patient with sensory loss A reduction in neuropathic foot problems will only be achieved if we remember that those patients with insensitive feet have lost their warning signal pain that ordinarily brings patients to their doctors. Thus, the care of a patient with sensory loss is a new challenge for which we have no training. It is difficult for us to understand, for example, that an intelligent patient would buy and wear a pair of shoes three sizes too small and come to the clinic with extensive shoe-induced ulceration. The explanation is simple: with reduced sensation, a very tight fit stimulates the remaining pressure nerve endings and is thus interpreted as a normal fit hence the common complaint when we provide patients with custom-designed shoes that "these shoes are too loose". We can learn much about the management of such patients from the treatment of patients with leprosy [28]. Although the cause of sensory loss is very different from that in diabetes, the end result is the same, thus work in leprosy has been very relevant to our understanding of the pathogenesis of diabetic foot lesions. He emphasized the power of clinical observation to his students and one remark of his that was very relevant to diabetic foot ulceration was that any patient with a plantar ulcer who walks into the clinic without a limp must have neuropathy. Brand also taught us that if we are to succeed, we must realize that with loss of pain there is also diminished motivation in the healing of, and prevention of, injury. The complex interactions of the neuropathies and other contributory factors in the causation of foot ulcers are summarized in Figure 44. In many series this has been associated with an annual risk of re-ulceration of up to 50%. Other long-term complications Patients with other late complications, particularly nephropathy, have been reported to have an increased foot ulcer risk. Those most at risk are patients who have recently started dialysis as treatment of their end-stage renal disease [30]. It must also be remembered that those patients with renal transplants and more recently combined pancreasrenal transplants are usually at high risk of ulceration even if normoglycemic as a result of the pancreas transplant. Peripheral neuropathy · Somatic · Autonomic Peripheral vascular disease Past history of foot ulcers Other long-term complication · End-stage renal disease · Visual loss Plantar callus Foot deformity Edema Ethnic background Poor social background 730 Foot Problems in Patients With Diabetes Chapter 44 confirmed this increased risk in Latinos, despite the foot pressures being actually lower in this group [35]. Pathway to ulceration It is the combination of two or more risk factors that ultimately results in diabetic foot ulceration (Figure 44. Applying this model to foot ulceration, a small number of causal pathways were identified: the most common triad of component causes, present in nearly two out of three incident foot ulcer cases, was neuropathy, deformity and trauma. Other simple examples of two component causeways to ulceration are loss of sensation and mechanical trauma such as standing on a nail, wearing shoes that are too small; or neuropathy and thermal trauma. Plantar callus Callus forms under weight-bearing areas as a consequence of dry skin (autonomic dysfunction), insensitivity and repetitive moderate stress from high foot pressure. The presence of callus in an insensate foot should alert the physician that this patient is at high risk of ulceration, and callus should be removed by the podiatrist or other trained health care professional. Elevated foot pressures Numerous studies have confirmed the contributory role that abnormal plantar pressures play in the pathogenesis of foot ulcers [3,32]. Foot deformity A combination of motor neuropathy, cheiroarthropathy and altered gait patterns are thought to result in the "high risk" neuropathic foot with clawing of the toes, prominent metatarsal heads, high arch and small muscle wasting (Figure 44. Many countries have now adopted the principle of the "annual review" for patients with diabetes, whereby every patient is screened at least annually for evidence of diabetic complications. Such a review can be carried out either in the primary care center or in a hospital clinic. Whereas a brief history was regarded as important, a careful examination of the foot including assessing its neurologic and vascular status was regarded as essential. There is a strong evidence base to support the use of simple clinical tests as predictors of risk of foot ulcers [11,37]. Whereas each potential simple neurologic clinical test has advantages and disadvantages, it was felt that the 10-g monofilament had much evidence to support its use hence the recommendation that assessment of neuropathy should comprise the 731 Part 9 Other Complications of Diabetes Table 44. Although this is a semi-quantitative test of sensation, it was included as many centers in both Europe and North America have such equipment. With respect to the vasculature, the ankle brachial index was recommended although it was realized that many centers in primary care may not be able to perform this in day-to-day clinical practice. Thus, an education program that focuses on reducing foot ulcers will be doomed to failure if patients do not believe that foot ulcers precede amputations. It is clear that much work is required in this area if appropriate education is to succeed in reducing foot ulcers and subsequently amputations. The potential for education and self-care at various points on the pathway to neuropathic ulceration is shown in Figure 44. There have been a small number of reports that assess educational interventions, but these have mostly been small singlecenter studies. In the most recently published study, even though the foot care education program was followed by improved foot care behavior, there is no evidence that such targeted education was associated with a reduced incidence of recurrent foot ulcers [43]. It has been suggested that patients find the concept of neuropathy difficult to understand: they are reassured because they have no discomfort or pain in their feet. This might include the use of the administered indicator plaster (Neuropad): when applied to the foot this changes color from blue to pink if there is normal sweating [44]. The absence of sweating such as in a high risk foot, results in no color change enabling patients to see that there is something different about their feet. This is a simple inexpensive semi-quantitative footprint mat that is able to identify high plantar pressures. Similarly, this can be used as an educational aid and might help the patient realize that specific areas under their feet are at particular risk of ulceration. In summary, foot care education is believed to be crucial in the prevention of ulceration, although there is little support for this from randomized controlled trials. Intervention for high-risk patients Any abnormality of the above screening test would put the patient into a group at higher risk of foot ulceration. Potential interventions are discussed under a number of headings, the most important of which is education. Education Previous studies have suggested that patients with foot ulcer risk lack knowledge and skills and consequently are unable to provide appropriate foot self-care [40]. Patients need to be informed of the risk of having insensate feet, the need for regular self-inspection, foot hygiene and chiropody/podiatry treatment as required, and they must be told what action to take in the event of an injury or the discovery of a foot ulcer. Attempted self-care has been reported in several cases to cause ulceration and similarly self-care of calluses should be discouraged.
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Tretinoin prevents age-related renal changes and stimulates antioxidant defenses in cultured renal mesangial cells. Drug Insight: 5alpha-reductase inhibitors for the treatment of benign prostatic hyperplasia. Prostate volume and serum prostate-specific antigen as predictors of acute urinary retention. Relationship among serum testosterone, sexual function, and response to treatment in men receiving dutasteride for benign prostatic hyperplasia. Eosinophilic crystals as a distinctive morphologic feature of a hyaline droplet nephropathy in a mouse model of acute myelogenous leukaemia. A phase I trial of etanidazole and hyperfractionated radiotherapy in children with diffuse brainstem glioma. Page 145 114740 137930 138630 108810 140380 115820 115620 136060 165590 123220 120050 107860 100110 121320 134120 134180 September 2010 Appendix 3: Master Bibliography American Urological Association, Inc. 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Basal cell proliferations of the prostate other than usual basal cell hyperplasia: a clinicopathologic study of 23 cases, including four carcinomas, with a proposed classification. Incidence, etiology, and risk factors for fever following acute spinal cord injury. Antibiotic resistance patterns of uropathogens in pediatric emergency department patients. Bladder volume at onset of reflux on initial cystogram predicts spontaneous resolution. Does ingestion of cranberry juice reduce symptomatic urinary tract infections in older people in hospital? Managing patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Role of cytologic criteria in the histologic diagnosis of Gleason grade 1 prostatic adenocarcinoma. Prostate size influences the outcome after presenting with acute urinary retention. Sustained-release alfuzosin and trial without catheter after acute urinary retention: a prospective, placebo-controlled. Postvoid residual urine in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia: pooled analysis of eleven controlled studies with alfuzosin. Alfuzosin 10 mg once daily in the management of acute urinary retention: results of a double-blind placebo-controlled study. Lower urinary tract symptoms suggestive of benign prostatic obstruction: what are the current practice patterns. Benign prostatic hyperplasia treated with saw palmetto: a literature search and an experimental case study.
It is better to assign the level of care depending on whether a patient has risk factors for foot ulceration cholesterol in eggs not bad discount 20 mg atorvastatin free shipping, such as impaired sensation or peripheral circulation cholesterol test over the counter 40mg atorvastatin with mastercard, and whether there are active foot lesions cholesterol chart tracker generic atorvastatin 20 mg online. This would allow patients with foot ulceration cholesterol zocor side effects buy 5mg atorvastatin visa, severe foot infection and Charcot arthropathy to receive the specialized attention they need mg of cholesterol in shrimp buy 20 mg atorvastatin. They need more multidisciplinary care cholesterol levels rising quickly order 5 mg atorvastatin free shipping, such as dietary counseling of carbohydrate counting or intensive teaching in the use of insulin infusion pumps. Therefore, this group of individuals is probably better managed at the specialist level. There is a great deal of uncertainty about the optimal line of division between primary care and specialist care, both from medical and economic points of view. There are some who believe that an HbA1c target of <7% (<53 mmol/ mol) should be adopted because, amongst other reasons, this is what can reasonably be expected at the primary care level. Others believe that this approach is not individualized enough, and could potentially discourage specialists and patients from aiming for even better glycemic control, even when it is appropriate. In our system, we have relied for many years on a report that is a hybrid of a computer report, containing numerical and factual data, supplemented by three free text messages addressing issues related to , respectively: 1 Glycemic control; 2 Complication status and management; and 3 Other important issues. The messages are intended to provide a management plan and explanation for proposed actions. Apart from serving the purpose of documentation and communication, the sending of this report for every patient who attends is, in our opinion, a powerful tool to update our primary care physicians regarding our policy of treatment, and the latest trend in diabetes management. This encourages them to adopt our strategies of diabetes management for other patients; thus, in a de facto way, promoting a more uniform treatment policy for the community. An example of this is our usual practice of maintaining oral antidiabetic agents when we commence someone on insulin treatment. Primary care doctors from out of our area often consider this to be a mistake, and stop the oral agents, while doctors in our area are more than happy to go along with it, having had it explained to them in the past. In this age of advanced telecommunication, it is possible to communicate through a centralized web-based database, or similar systems to which various health professionals could have access. Technology that enables immediate access to test results means that the clinical consultation is enhanced. For example, a chronic care program conducted in rural Pennsylvania established information systems in the community that allowed for rapid turn around of laboratory results. Local physicians were made responsible for collecting and responding to data, resulting in improved patient outcomes [33]. Patient tracking systems for regular follow-up have also been shown to improve quality of care at the process level and to decrease the number of patients lost to follow-up [13,3436]; however, while these systems can undoubtedly be helpful in transmitting factual information, they are not as good for individualized advice, which we believe to be the essence of cementing a good community and specialist relationship. The future challenge the challenge ahead is to provide accessible and affordable quality care to an increasing number of people with diabetes. If diabetes care is to achieve the health care benefits that the diabetes research described in this textbook has made possible, it must be tackled at both the community and specialist levels. In this regard, the complementarity of primary and specialist care has a pivotal role and is a relationship that must be carefully considered by health care planners. Communication between primary and specialist care Timely communication is crucial in promoting a seamless 964 Figure 56. Intensified multifactorial intervention and cardiovascular outcome in type 2 diabetes: the Steno-2 study. Remission to normoalbuminuria during multifactorial treatment preserves kidney function in patients with type 2 diabetes and microalbuminuria. Intensive integrated therapy of type 2 diabetes: implications for long-term prognosis. Target intervention against multiple risk markers to reduce cardiovascular disease in patients with type 2 diabetes. Multi-targeted and aggressive treatment of patients with type 2 diabetes at high risk: what are we waiting for? Cost-effectivenss of intensified versus conventional multifactorial intervention in type 2 diabetes. A single visit diabetes complication assessment service: a complement to diabetes management at the primary care level. A comparison of diabetes clinics with different emphasis on routine care, complications assessment and shared care. Implementing the chronic care model for improvements in diabetes practices and outcomes in primary care: the University of Pittsburgh Medical Center experience. Effect of multiple patient reminders in improving diabetic retinopathy screening: a randomized trial. Sharing the care of diabetic patients between hospital and general practitioners: does it work? The pattern of diabetes care in New South Wales: a five-year analysis using Medicare Occasions of Service Data. Quality of care for patients with type 2 diabetes in primary care in Norway is improving. German Diabetes Management Programs are appropriate for restructuring care according to the Chronic Care Model. Cost-effectiveness of medical nutrition therapy provided by dietitians for persons with non-insulin dependent diabetes mellitus. Nurse case management to improve glycaemic control in diabetic patients in a health maintenance organization: a randomized trial. Application of a diabetes managed care program: the feasibility of using nurses and a computer system to provide effective care. Renal assessment practices and the effect of nurse case management of health maintenance organization patients with diabetes. Effect of a nurse-directed diabetes disease management program on urgent care/emergency room visits and hospitalisations in a minority population. Intensified multifactorial intervention in patients with type 2 diabetes and microal- 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 968 57 Keypoints the Role of the Multidisciplinary Team Wing-Yee So & Juliana C. In Europe and China, 3040% of patients with acute myocardial infarction have a known history of diabetes. In the remaining subjects, 70% of patients have either diabetes or intermediate hyperglycemia on formal 75-g oral glucose tolerance testing [2,3]. Both are important considerations in the majority of cardiovascular deaths worldwide, which are estimated to be 18 million annually. The number of people with diabetes is projected to increase from 285 million in 2010 to 435 million by 2030 [4]. The resulting increase will lead to considerable losses in productivity as well as greatly increasing the burden on health care systems. The total direct annual costs of diabetes in eight European countries were estimated at 29 billion, with an estimated yearly cost of 2834 per patient [6]. The per capita cost was estimated to be $13 243 for individuals with diabetes com- pared to $2560 for those without [7]. In China, one of the countries with the most rapid increase in diabetes prevalence, $558 billion in national income is expected to be lost over the next 10 years as a result of premature deaths caused by non-communicable diseases including heart disease, stroke and diabetes [8]. Evidence for optimization of diabetes control To date, most evidence supporting the beneficial effects of optimal diabetes care on clinical outcomes [10,13,14] were collected under closely supervised clinical trial conditions. There was progressive deterioration in glycemic control once these intensively treated patients returned to their usual care setting; however, patients previously treated conventionally also improved, and both groups converged to achieve HbA1c levels of 8% (64 mmol/mol) [15]. Despite this convergence, patients previously treated intensively maintained over 50% risk reduction in all diabetes-associated complications, including cardiovascular events [16]. Findings from these landmark studies clearly demonstrate the beneficial effects of achieving risk factor control during the early course of disease to achieve long-term benefits. Diabetes care the reality Despite the evidence, national and international surveys have indicated that diabetes management remains suboptimal, regardless of the studied populations and health care settings. It should also be remembered that most of these recommendations, guidelines, surveys and studies emanate from settings, countries and areas that are relatively well-resourced. The levels of care were noted to be suboptimal, especially in females and in those under the age of 45 years [22,23]. Thus, between these surveys, some improvements were documented but many problems remained. Despite much data, there has been little change in average values attained or percentage of patients reaching treatment goals. The results were similar in both developed and low and middle income countries [14,21,2426], different health care settings, primary care [27 32] and specialist centers [3336]. Emerging evidence of the importance of blood pressure control led to the target blood pressure being revised to <130/80 mmHg. This is not accompanied by further improvement in terms of rate of achievement of targets. There are obvious limitations in these studies including heterogeneity of populations in different studies, retrospective reviews, incomplete documentation for medical record review and inaccuracy for claims data. Despite the limitations and lack of comparability of the many studies, the results summarized in Tables 57. It should also be noted that, most of these surveys come from well-resourced settings and developed countries, where laboratory assessment for HbA1c is readily available. The Institute of Medicine has defined quality of care as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge" [38,39]. There is ongoing controversy as to the degree to which outcomes can be directly related to processes of care, yet both are considered as important measures of quality. Thus, the degree of adherence to recommended guidelines, based on available clinical evidence, provides guidance to the degree of quality of care. In early years, less than one-third of patients received HbA1c monitoring [14,40,41]. Interpretation of the adequacy of glycemic control is affected by the laboratory methods used and the corresponding reference range, which might vary across studies. Recently, more than 90% of patients have HbA1c regularly monitored in specialist clinics such as the Steno Diabetes Center [45] and in some primary care settings [30,46]. Although there appears to have been some improvements in the care processes over time, this has not been matched by improvement in rates of achieving treatment targets (Tables 57. In addition, the level of care received by many patients does not meet recommended standards. Only 72% of the subjects visited a health care provider for diabetes care at least once a year, and approximately 60% received complication screening. The factors that compromise quality of care have been examined in various studies, but have not been well understood. Discrepancy between evidence-based care and reality the efficacy of optimization of diabetes control has been confirmed in randomized controlled trials conducted with stringent clinical trial protocols; however, despite improvements in some processes of care such as monitoring of HbA1c, this has not been matched by improvement in rates of achieving treatment targets. Patients Drug compliance by patients receiving chronic medications is consistently reported to be less than 50%, often because of insufficient education and reinforcement [5456]. Moreover, there is considerable heterogeneity in the patterns and rates of nonadherence to individual components. Thus, the extent to which people with diabetes adhere to one aspect of the regimen might not cor- 972 the Role of the Multidisciplinary Team Chapter 57 Table 57. Interpretation of the adequacy of dyslipidemia treatment is affected by the laboratory methods used and thus the corresponding reference range might vary across studies. For simplicity, the table only describes the absolute values cited in the original papers, and direct comparisons between studies may not be valid. Previous studies have shown that only 69% of people with diabetes follow a diet and less than half engage in regular exercise [57]. The reported adherence to self-monitoring of blood glucose ranges from 53% to 70% [58]. Earlier studies have indicated that only 7% of patients with diabetes adhere to all aspects of the treatment regimen [59], while over half made errors with insulin dosage and three-quarters of patients were judged to be in an "unacceptable" category regarding the quality, quantity and timing of meals [60]. In attempts to extrapolate results from clinical trials to daily practice, it is important to individualize interventions taking into account all potential factors. For example, in the elderly, side effects of interventions must be balanced against long-term benefits, limited life expectancy and co-morbidities. Other factors such as education level, access to care, compliance and motivation may also contribute to patient adherence, in addition to treatment-related factors such as adverse effects, polypharmacy and cost [42,43,49]. It is recommended that people with diabetes should be educated about the nature of the disease with particular focus on chronicity and long-term complications, as well as preventability. Physicians the key role of health care providers is to equip people with diabetes with knowledge and skills related to self-management, to individualize medical and behavioral regimens, to assist with informed decisions, and provide social and emotional support via a collaborative relationship [61,62]. An important factor is the inertia of physicians in failing to modify the management of patients in response to an abnormal clinical result [63,64]. Despite the complexity and rapid advances in diabetes management, generalists often did not perceive the need for further training in the field of diabetes [6669]. Involvement of other non-medical health care professionals may also not be welcomed in some traditional settings. Health care system Traditional medical practice is organized to respond quickly to acute problems, but does not adequately serve the needs of 973 Part 11 Delivery and Organization of Diabetes Care Table 57. Health care setting Number of patients Survey period Method Performance index (frequency of HbA1c measurements in last year or % of patients with at least 1 HbA1c measured in last year) 1618% of physicians measured every 23 months 28. Health care systems need to ensure that the best possible treatment regimens are administered in order to control disease, alleviate symptoms, inform and support. Thus, suboptimal quality of care is often caused by combinations of factors relating to the affected individual, to the medical care personnel and to the system of health care delivery. In this survey, there was considerable heterogeneity between regions of patient-related factors. The problem is particularly marked in low and middle income settings where it is exacerbated by multiple demands upon severely limited resources including those imposed by a continuing burden of infectious diseases and other issues such as accidents and injuries. The evolving concept of disease management Implementation of quality structured care It will be clear from the previous sections that although optimal care improves clinical outcomes in clinical trial settings, this is often not achieved in real clinical situations for the reasons discussed. This has led to attempts to develop models of care based on multidisciplinary approaches. In recent years, there has been increasing emphasis on management via coordination and organization of individual components of care into a structured system. The latter is further supported by reinforcement through multiple contacts, including not only physician appointments, but also telephone reminders and visits to other health care professionals such as nurse practitioners, dietitians and pharmacists.
Also is a 4.2 cholesterol ratio good purchase 5 mg atorvastatin free shipping, identify available computers and information needed for use cholesterol levels on blood test discount atorvastatin 20 mg, including the type of computer ratio van cholesterol 10 mg atorvastatin overnight delivery, operational system cholesterol levels new guidelines discount atorvastatin 5mg free shipping, and access to the Internet cholesterol test method order 10 mg atorvastatin with visa. V 80 V Virginia Department of Education cholesterol lowering diet and exercise plan buy 20 mg atorvastatin otc, Office of Special Education and Student Services Models of Best Practice in the Education of Students with Autism Spectrum Disorders: Preschool and Elementary V May 2011 Steps 5 and 6. Identify, Select, and Install Appropriate Software Determine the program that may be used to provide instruction. Complete a Task Analysis of Steps for Using Software Complete a task analysis of the steps for accessing and using the designated program so he or she can use the computer more independently. Teach the Program to Others Who Support the Student Teach those who support the student how to use the program, including other teachers, classroom assistants, peers, and family members. Teach the Student Basic Computer Skills, if Necessary Provide opportunities for students to learn basic computer skills. Skills include: V sitting at the computer; V wearing headphones (if necessary); V looking at, listening to , and responding to the computer screen; V using a mouse and/or keyboard (and possibly other equipment, such as a touch screen); V taking turns; or V treating the computer equipment with care. Introduce Student to the Program, Provide Opportunities for Use, and Offer Ongoing Support Teach student to learn how to use the program using the task analysis and targeted instruction. Collect Data on Acquisition of Target Skill Collect and analyze data on the acquisition of the target skill. A variety of differential reinforcement strategies can be used to increase positive behaviors and decrease interfering behaviors. Identify the Interfering Behavior Define the behavior that interferes with learning and gather relevant information including topography, frequency, and intensity to provide a thorough description. Determine the Function of the Interfering Behavior Conduct a Functional Behavioral Assessment and identify the function of the interfering behavior. Identify Data Collection Measures and Collect Baseline Data Identify data collection measures to be used to assess the interfering behavior and collect baseline data to determine the frequency, topography, and intensity/ severity. Select a Differential Reinforcement Procedure Determine one or more of the following differential reinforcement procedures to use to address the function of the interfering behavior: 1. Differential Reinforcement Procedures Topography Unacceptable/ dangerous/ student looks extremely odd. Implement the Intervention Implement the intervention plan that has been developed by following the schedule of reinforcement outlined and explicitly teaching the replacement or alternative skills. Review and Modify the Intervention Plan Modify the intervention plan by determining the progress towards reduction of the interfering behavior and increase of replacement or alternative skills. Its limitations involve lack of reinforcement of student spontaneity and difficulty with generalization. Break the Skill Down into Teachable Steps Complete a task analysis of the skill, breaking the skill into small teachable steps. Identify each step of the skill and list in sequential order from entry to mastery level. Set Up the Data Collection System Select or create data sheets specifically designed for the skill being taught that will provide for collection of trial by trial data and a visual summary of the data. Designate Location(s) Determine the possible locations where teaching will take place. If the student responds appropriately, deliver a reinforcer and mark the trial as correct 3. Virginia Department of Education, Office of Special Education and Student Services V 83 V Models of Best Practice in the Education of Students with Autism Spectrum Disorders: Preschool and Elementary V May 2011 b. If the student does not respond, provide corrective feedback and begin the trial again with the same level of prompting If the student responds incorrectly, record the trial and begin the trial again with increased prompting Step 7. Conduct Massed Trial Teaching Conduct teaching using massed trials, by repeating the same learning trial several times in a row, ensuring that the student is successful multiple times at whatever step of the skill is being taught. Begin the teaching episode with a maintenance trial (demonstration of a skill already mastered) and record the result Present instruction on the teaching target (move to this step only if the student passed the maintenance trial) If the student responds correctly on the first trial, repeat the instruction several more times and record the results If the student is unsuccessful, repeat the trial multiple times adding an increased level of assistance. Review and Modify Review data and modify the program to reflect the progress or lack of progress made. If progress has occurred, add learned skills to the list of maintenance items to be reviewed and target skills for generalization by practicing skills in other settings, with other adults, and with other stimuli. Extinction Skills and intervention goals addressed Extinction is used to reduce or eliminate the occurrence of an interfering behavior, especially harmful behaviors. Overview Extinction is a reinforcement strategy that is used with students exhibiting interfering behaviors in order to eliminate the behavior. When using extinction, reinforcement is withheld when the interfering behavior occurs in an effort to reduce or eliminate the reoccurrence of the interfering behavior. It is based on the principle that if the reinforcement for the behavior is withheld then the behavior is likely to stop as it is no longer being reinforced. Extinction usually occurs with differential reinforcement as desired behaviors are differentially reinforced while interfering behaviors experience extinction. During the use of extinction it is likely that the interfering behavior will experience a temporary increase. Identify the interfering behavior Identify the interfering behavior and its function through a Functional Behavioral Assessment. Identify the reinforcer Determine what is reinforcing the behavior and effectively avoid delivering the reinforcer to the interfering behavior. Conduct Discrimination Training Teach the student to discriminate the teaching target from other similar items by systematically presenting the mastered item with distracters. Teach the student to generalize a concept or item by reteaching the concept with several different stimuli. V 84 V Virginia Department of Education, Office of Special Education and Student Services Models of Best Practice in the Education of Students with Autism Spectrum Disorders: Preschool and Elementary V May 2011 Step 3. Differentially reinforce Differentially reinforce the desired behavior by providing the reinforcer following the demonstration of a positive or replacement behavior while simultaneously not delivering any type of reinforcement to the interfering behavior. Functional Communication is more effective than just teaching expressive language skills in general as they serve a specific purpose for the student. It is important that the new replacement behavior match the function of the interfering behavior. Additionally, the variables that maintain the interfering behavior must be accessed through a functional-based assessment procedure in order to adequately reinforce the replacement behavior. Conduct a Functional Behavioral Assessment Conduct a Functional Behavioral Assessment to determine the function of an interfering behavior. Identify a Replacement Behavior as a Substitute for the Interfering Behavior Determine the Functional Communication that will serve the same purpose as the interfering behavior. Select a replacement behavior that is efficient, acceptable, and recognized by all who interact with the student. Determine when the Functional Communication will be taught based on the results of the Functional Behavioral Assessment. Table 13 provides examples of student behavior and Functional Communication replacements. Hits Escape from work Virginia Department of Education, Office of Special Education and Student Services V 85 V Models of Best Practice in the Education of Students with Autism Spectrum Disorders: Preschool and Elementary V May 2011 Step 4. Teach the Replacement Functional Communication by Manipulating the Environment and Using Effective Prompting Procedures Teach the replacement behavior in the environments where the interfering behavior occurs. Manipulate materials or activities to provide opportunities for the repeated practice of the replacement behavior. For example, the teacher might serve a small portion at snack so the student must present a picture of "cracker" multiple times or the teacher may purposefully engage in another activity so the student has to gain attention by raising her hand. Prompt the student to use the replacement behavior using a prompt that ensures errorless learning. Shape the production of the replacement behavior by reinforcing closer approximations until it is the desired production. Target generalization of the Functional Communication by teaching the replacement behavior with multiple communication partners and in multiple settings. Monitor Student Progress Data collection is monitored to ensure the student replaces the interfering behavior and is able to generalize the Functional Communication. The following questions may be helpful during this problem-solving process: V Has the function of the behavior been identified correctly? V Was instruction provided in environments where the interfering behavior typically occurs? Naturalistic Interventions Skills and intervention goals addressed Naturalistic intervention can be used to facilitate communication and social skills, which may include things like expressive vocabulary, speech intelligibility, use of gesture, shared attention, and turn taking. By definition, Naturalistic Intervention is used in daily routines throughout the day to develop skills. A key feature of this strategy is using materials, toys, and activities that will motivate the student to engage in the target behavior and will promote generalization of skills. Data collection focuses on: V antecedents, V prompts required to produce the replacement behavior, V frequency of the replacement behaviors, and V frequency of the interfering behavior. V 86 V Virginia Department of Education, Office of Special Education and Student Services Models of Best Practice in the Education of Students with Autism Spectrum Disorders: Preschool and Elementary V May 2011 target behaviors. These behavioral techniques include modeling, mand-models, time delay, and incidental teaching. Identify a Target Behavior Identify a specific target behavior/skill to be the focus of the intervention. This target behavior may focus on prelinguistic or linguistic communication and/or social skills. Examples of specific skills are: V Connor will use the pronouns he, she, and it correctly. Identify Contexts and Instructional Format for Intervention Identify where and how Naturalistic Intervention will be implemented. Choose motivating materials/activities to engage students and promote the use of targeted skills. Manage and distribute teaching materials in a way that encourages students to learn the target skill. The teacher should be "the keeper of the goods" and distribute the materials in a manner that elicits student performance. Naturalistic Intervention should take place throughout the day in the context of daily routines / schedules. Plan to implement three instructional strategies within daily routines / schedules to teach desired skills using Naturalistic Interventions: a. Planned activities are set-up in advance to provide structured opportunities for students to practice the target behavior. The intention is for Ruby to be enticed by the small pieces and then engage in turn taking while playing the game. Virginia Department of Education, Office of Special Education and Student Services V 87 V Models of Best Practice in the Education of Students with Autism Spectrum Disorders: Preschool and Elementary V May 2011 Step 5. Elicit the Target Behavior Elicit the target behavior using interaction techniques and, if necessary, behavioral strategies like prompting and modeling. Engage the student in a language-rich and student-centered interaction in which the teacher is highly attuned and responsive to the communicative attempts of the student. Remember the environment has already been arranged to elicit specific targets (Step 4), so either activity should lead to the desired behavior. Another example is to provide a student with several items known to be motivating, such as dinosaurs, trains, and markers. Allow the student to choose the desired item then provide engagement with the item chosen. The teacher is positioned to share face-to-face interactions in order to facilitate shared attention. Be aware of even the most subtle communicative attempts and respond to these attempts. When a student is verbal, especially at the one- to three-word phrase level, the teacher can build on what the student says, thereby demonstrating more linguistically sophisticated options. Establishing shared attention, Presenting a verbal or physical model, Repeating the response and providing the requested material if the student responds correctly, Providing another model if the student does not respond or responds inaccurately, Continuing these steps until student demonstrates mastery with the target behavior, Fading the use of the model, and Expanding the model provided and the response desired from the student. Mand-modeling: Mand-modeling incorporates questions, choice, direction into the activity prior to initiating a modeling procedure. Establishing shared attention, Presenting a verbal direction (mand) or question, Repeating the response and providing the requested material if the student responds correctly, V 88 V Virginia Department of Education, Office of Special Education and Student Services Models of Best Practice in the Education of Students with Autism Spectrum Disorders: Preschool and Elementary V May 2011 d. Providing another model if the student does not respond or responds inaccurately, Modeling the appropriate behavior and providing the material/activity if the student attempts to respond but does not meet the target level, Continuing these steps until the student demonstrates mastery with the target g. Table 14 illustrates how mand-modeling can be used to teach the use of two-word utterances. Mand-modeling Procedure Example Steps Establish shared attention Provide a verbal direction (mand) or question Student responds correctly Example Sasha and her teacher are having snack at the table where enticing snacks are located. Teacher says, "Tell me what you want, Sasha" or gives a choice question, "Do you want apples or crackers? Establishing shared attention and create an opportunity for the student to respond. Setting up the environment, establish shared attention, and create an opportunity for the student to respond, Waiting for student to initiate the behavior, Responding with a request for the behavior, if the student does not initiate the target response, Prompting for elaboration until the student responds appropriately if the student does b. Virginia Department of Education, Office of Special Education and Student Services V 89 V Models of Best Practice in the Education of Students with Autism Spectrum Disorders: Preschool and Elementary V May 2011 Table 15. She waits, with her hands up as if to push, and has an expectant look on her face. Student demonstrates behavior at the target level Student does not initiate at the target level After the mand or model is provided, student responds correctly Student does not give the target response but makes an attempt. Use Data Collection to Monitor Student Progress and Determine Next Steps Review data and modify the program to reflect the progress or lack of progress made. Peers are systematically instructed in ways of engaging with students in both teacher directed and student directed activities.
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