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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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Bing Shen, MD
Buse 14 # European Association for the Study of Diabetes and American Diabetes Association 2018 Abstract the American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the prior position statements top medicine proven 20 mg arava, published in 2012 and 2015 medicine 75 yellow cheap 10 mg arava amex, on the management of type 2 diabetes in adults symptoms jaw pain discount arava 20mg fast delivery. A systematic evaluation of the literature since 2014 informed new recommendations in treatment 1-3 buy discount arava 10 mg line. These include additional focus on lifestyle management and diabetes selfmanagement education and support. For those with obesity, efforts targeting weight loss, including lifestyle, medication and surgical interventions, are recommended. This article is being simultaneously published in Diabetes Care and Diabetologia by the American Diabetes Association and the European Association for the Study of Diabetes. The expanding number of glucose-lowering treatments-from behavioural interventions to medications and surgery-and growing information about their benefits and risks provides more options for people with diabetes and providers, but can complicate decision making. Marked hyperglycaemia is associated with symptoms including frequent urination, thirst, blurred vision, fatigue and recurring infections. Beyond alleviating symptoms, the aim of blood glucose lowering (hereafter, referred to as glycaemic management) is to reduce long-term complications of diabetes. Good glycaemic management yields substantial and enduring reductions in onset and progression of microvascular complications. This benefit has been demonstrated most clearly early in the natural history of the disease in studies using metformin, sulfonylureas and insulin but is supported by more recent studies with other medication classes. Because the benefits of intensive glucose control emerge slowly, while the harms can be immediate, people with longer life expectancy have more to gain from intensive glucose control. A reasonable HbA1c target for most non-pregnant adults with sufficient life expectancy to see microvascular benefits (generally ~10 years) is around 53 mmol/mol (7%) or less [6]. Glycaemic treatment targets should be individualised based on patient preferences and goals, risk of adverse effects of therapy. This requires control of glycaemia and cardiovascular risk factor management, regular follow-up and, importantly, a patientcentred approach to enhance patient engagement in self-care activities [1]. Careful consideration of patient factors and preferences must inform the process of individualising treatment goals and strategies [2, 3]. This consensus report addresses the approaches to management of glycaemia in adults with type 2 diabetes, with the goal of reducing complications and maintaining quality of life in the context of comprehensive cardiovascular risk management and patient-centred care. These recommendations are not generally applicable to patients with monogenic diabetes, secondary diabetes or type 1 diabetes, or to children. Data sources, searches and study selection the writing group accepted the 2012 [4] and 2015 [5] editions of this position statement as a starting point. Reference lists were scanned in eligible reports to identify additional articles relevant to the subject. Papers were grouped according to subject and the authors reviewed this new evidence to inform the consensus recommendations. The draft consensus recommendations were peer reviewed (see Acknowledgements), and suggestions incorporated as deemed appropriate by the authors. Nevertheless, though evidence based, the recommendations presented herein are the opinions of the authors. Glucose management: monitoring Glycaemic management is primarily assessed with the HbA1c test, which was the measure studied in trials demonstrating the benefits of glucose lowering [2]. Because there is variability in the measurement of HbA1c, clinicians should exercise judgement, particularly when the result is close to the threshold that might prompt a change in therapy. Discrepancies between measured HbA1c and measured or reported glucose levels should prompt consideration that one of these may not be reliable [12]. People with diabetes and the healthcare team should use the data in an effective and timely manner. In people with type 2 diabetes not using insulin, routine glucose monitoring is of limited additional clinical benefit while adding burden and cost [13, 14]. However, for some individuals, glucose monitoring can provide insight into the impact of lifestyle and medication management on blood glucose and symptoms, particularly when combined with education and support. Novel technologies, such as continuous or flash glucose monitoring, provide more information. However, in type 2 diabetes, they have been associated with only modest benefits [15]. Shared decision making, facilitated by decision aids that show the absolute benefit and risk of alternative treatment options, is a useful strategy to arrive at the best treatment course for an individual [1720]. Providers should evaluate the impact of any suggested intervention, including self-care regimens, in the context of cognitive impairment, limited literacy, distinct cultural beliefs and individual fears or health concerns given their impact on treatment efficacy. The best outcomes are achieved in those programmes with a theory-based and structured curriculum, and with contact time of over 10 h. While online programmes may reinforce learning, there is little evidence they are effective when used alone [27]. Consensus recommendation Facilitating medication adherence should be specifically considered when selecting glucose-lowering medications. Principles of care Consensus recommendation Providers and healthcare systems should prioritise the delivery of patient-centred care. Providing patient-centred care that acknowledges multi-morbidity, and is respectful of and responsive to individual patient preferences and barriers, including the differential costs of therapies, is essential to effective diabetes management [16]. Nevertheless, the broad components are similar are pertinent to all aspects of diabetes care. Multiple factors contribute to inconsistent medication use and treatment discontinuation, including patient-perceived lack of medication efficacy, fear of hypoglycaemia, lack of access to medication and adverse effects of medication [37]. Medication adherence (including persistence) varies across medication classes and careful consideration of these differences may help improve outcomes [38]. Ultimately, patient preference is a major factor driving the choice of medication. Even in cases where clinical characteristics suggest the use of a particular medication based on the available evidence from clinical trials, patient preferences regarding route of administration, injection devices, side effects or cost may prevent their use by some individuals [39]. Therapeutic inertia, sometimes referred to as clinical inertia, refers to failure to intensify therapy when treatment targets are not met. The causes of therapeutic inertia are multifactorial, occurring at the level of the practitioner, patient and/or healthcare system [40]. Interventions targeting therapeutic inertia have facilitated improved glycaemic control and timely insulin intensification [41, 42]. For example, multidisciplinary teams that include nurse practitioners or pharmacists may help reduce therapeutic inertia [43, 44]. A fragmented healthcare system may contribute to therapeutic inertia and impair delivery of patient-centred care. A coordinated chronic care model, including self-management support, decision support, delivery system design, clinical information systems, and community resources and policies, promotes interaction between more empowered patients and better prepared and proactive healthcare teams [45]. Recommended process for glucose-lowering medication selection: where does new evidence from cardiovascular outcomes trials fit in? In prior consensus statements, efficacy in reducing hyperglycaemia, along with tolerability and safety were primary factors in glucose-lowering medication selection. Patient preferences, glycaemic targets, comorbidities, polypharmacy, side effects and cost were additional important considerations. Figure 2 describes our new consensus approach to glucose lowering with medications in type 2 diabetes. Other factors affect the choice of glucose-lowering medications, particularly in the setting of patient-centred care. It is not clear whether there are true drug class effects with different findings for individual medications due to differences in trial design and conduct, or whether there are real differences between medications within a drug class due to properties of the individual compounds. Where the current evidence is strongest for a specific medication within a class, it is noted. Furthermore, most (~70% across trials) participants were treated with metformin at baseline. However, dose adjustment or discontinuation of background medications may be required to avoid hypoglycaemia when adding a new agent to a regimen containing insulin, sulfonylurea or glinide therapy, particularly in patients at or near glycaemic goals. Two short-term studies of liraglutide in patients with reduced ejection fraction suggested a lack of benefit in this setting [56, 57]. The full range of therapeutic options: lifestyle management, medication and obesity management this section summarises the lifestyle, medication and obesity management therapies that lower glucose or improve other outcomes in patients with type 2 diabetes. A more comprehensive discussion of these issues is available elsewhere [3, 21, 65]. Basic information about specific options in each category of therapy is summarised in Table 2.
In an embryofetal development study in pregnant cynomolgus monkeys symptoms mercury poisoning buy 20mg arava overnight delivery, subcutaneous doses of 0 symptoms 7dpiui arava 20 mg mastercard. Pharmacologically mediated medications just for anxiety order arava 20mg, marked initial maternal body weight loss and reductions in body weight gain and food consumption coincided with the occurrence of sporadic abnormalities (vertebra medications quizlet buy arava 10 mg, sternebra, ribs) at 0. In a pre- and postnatal development study in pregnant cynomolgus monkeys, subcutaneous doses of 0. Pharmacologically mediated marked initial maternal body weight loss and reductions in body weight gain and food consumption coincided with an increase in early pregnancy losses and led to delivery of slightly smaller offspring at 0. Semaglutide was present in the milk of lactating rats, however, due to species-specific differences in lactation physiology, the clinical relevance of these data are not clear (see Data). Data In lactating rats, semaglutide was detected in milk at levels 3-12 fold lower than in maternal plasma. No overall differences in safety or efficacy were detected between these patients and younger patients, but greater sensitivity of some older individuals cannot be ruled out. The main protraction mechanism of semaglutide is albumin binding, facilitated by modification of position 26 lysine with a hydrophilic spacer and a C18 fatty di-acid. A minor modification was made in position 34 to ensure the attachment of only one fatty di-acid. The principal mechanism of protraction resulting in the long half-life of semaglutide is albumin binding, which results in decreased renal clearance and protection from metabolic degradation. Semaglutide reduces blood glucose through a mechanism where it stimulates insulin secretion and lowers glucagon secretion, both in a glucose-dependent manner. Thus, when blood glucose is high, insulin secretion is stimulated, and glucagon secretion is inhibited. The mechanism of blood glucose lowering also involves a minor delay in gastric emptying in the early postprandial phase. All pharmacodynamic evaluations were performed after 12 weeks of treatment (including dose escalation) at steady state with semaglutide 1 mg. Fasting and Postprandial Glucose Semaglutide reduces fasting and postprandial glucose concentrations. In patients with type 2 diabetes, treatment with semaglutide 1 mg resulted in reductions in glucose in terms of absolute change from baseline and relative reduction compared to placebo of 29 mg/dL (22%) for fasting glucose, 74 mg/dL (36%) for 2-hour postprandial glucose, and 30 mg/dL (22%) for mean 24-hour glucose concentration (see Figure 1). Mean 24-hour plasma glucose profiles (standardized meals) in patients with type 2 diabetes before (baseline) and after 12 weeks of treatment with semaglutide or placebo 250 5 once-weekly administration. Distribution the mean apparent volume of distribution of semaglutide following subcutaneous administration in patients with type 2 diabetes is approximately 12. Elimination the apparent clearance of semaglutide in patients with type 2 diabetes is approximately 0. With an elimination half-life of approximately 1 week, semaglutide will be present in the circulation for about 5 weeks after the last dose. Metabolism the primary route of elimination for semaglutide is metabolism following proteolytic cleavage of the peptide backbone and sequential beta-oxidation of the fatty acid sidechain. Excretion the primary excretion routes of semaglutide-related material are via the urine and feces. Glucagon Secretion Semaglutide lowers the fasting and postprandial glucagon concentrations. In patients with type 2 diabetes, treatment with semaglutide resulted in the following relative reductions in glucagon compared to placebo, fasting glucagon (8%), postprandial glucagon response (14-15%), and mean 24 hour glucagon concentration (12%). Glucose dependent insulin and glucagon secretion Semaglutide lowers high blood glucose concentrations by stimulating insulin secretion and lowering glucagon secretion in a glucose-dependent manner. With semaglutide, the insulin secretion rate in patients with type 2 diabetes was similar to that of healthy subjects (see Figure 2). Mean insulin secretion rate versus glucose concentration in patients with type 2 diabetes during graded glucose infusion before (baseline) and after 12 weeks of treatment with semaglutide or placebo and in untreated healthy subjects 14 Insulin secretion rate (pmol/kg/min) 12 10 8 6 4 2 0 90 100 110 Specific Populations Based on a population pharmacokinetic analysis, age, sex, race, and ethnicity, and renal impairment do not have a clinically meaningful effect on the pharmacokinetics of semaglutide. The effects of intrinsic factors on the pharmacokinetics of semaglutide are shown in Figure 3. Body weight test categories (55 and 127 kg) represent the 5% and 95% percentiles in the dataset. This was also shown for subjects with both type 2 diabetes and renal impairment based on data from clinical studies (Figure 3). Patients with Hepatic impairment - Hepatic impairment does not have any impact on the exposure of semaglutide. The pharmacokinetics of semaglutide were evaluated in patients with different degrees of hepatic impairment (mild, moderate, severe) compared with subjects with normal hepatic function in a study with a single-dose of 0. The delay of gastric emptying with semaglutide may influence the absorption of concomitantly administered oral medicinal products. The potential effect of semaglutide on the absorption of co-administered oral medications was studied in trials at semaglutide 1 mg steady-state exposure. No clinically relevant drug-drug interaction with semaglutide (Figure 4) was observed based on the evaluated medications; therefore, no dose adjustment is required when co-administered with semaglutide. Gastric emptying Semaglutide causes a delay of early postprandial gastric emptying, thereby reducing the rate at which glucose appears in the circulation postprandially. Similar exposure is achieved with subcutaneous administration of semaglutide in the abdomen, thigh, or upper arm. In patients with type 2 diabetes, semaglutide exposure increases in a dose-proportional manner for once-weekly doses of 0. Metformin and oral contraceptive drug (ethinylestradiol/levonorgestrel) were assessed at steady state. Warfarin (S-warfarin/Rwarfarin), digoxin and atorvastatin were assessed after a single dose. A statistically significant increase in thyroid C-cell adenomas and a numerical increase in C-cell carcinomas were observed in males and females at all dose levels (2X human exposure). In a 2-year carcinogenicity study in Sprague Dawley rats, subcutaneous doses of 0. A statistically significant increase in thyroid C-cell adenomas was observed in males and females at all dose levels, and a statistically significant increase in thyroid C-cell carcinomas was observed in males at 0. Human relevance of thyroid C-cell tumors in rats is unknown and could not be determined by clinical studies or nonclinical studies [see Boxed Warning and Warnings and Precautions (5. Semaglutide was not mutagenic or clastogenic in a standard battery of genotoxicity tests (bacterial mutagenicity (Ames), human lymphocyte chromosome aberration, rat bone marrow micronucleus). In a combined fertility and embryo-fetal development study in rats, subcutaneous doses of 0. Males were dosed for 4 weeks prior to mating, and females were dosed for 2 weeks prior to mating and throughout organogenesis until Gestation Day 17. In females, an increase in oestrus cycle length was observed at all dose levels, together with a small reduction in numbers of corpora lutea at 0. These effects were likely an adaptive response secondary to the pharmacological effect of semaglutide on food consumption and body weight. Overall, 64% were White, 8% were Black or African American, and 21% were Asian; 30% identified as Hispanic or Latino ethnicity. Overall, 68% were White, 5% were Black or African American, and 25% were Asian; 17% identified as Hispanic or Latino ethnicity. Overall, 84% were White, 7% were Black or African American, and 2% were Asian; 24% identified as Hispanic or Latino ethnicity. Overall, 78% were White, 5% were Black or African American, and 17% were Asian; 12% identified as Hispanic or Latino ethnicity. Overall, 77% were White, 9% were Black or African American, and 11% were Asian; 20% identified as Hispanic or Latino ethnicity. Insulin glargine dose adjustments occurred throughout the trial period based on self-measured fasting plasma glucose before breakfast, targeting 71 to <100 mg/dL. In addition, investigators could titrate insulin glargine at their discretion between study visits. Only 26% of patients had been titrated to goal by the primary endpoint at week 30, at which time the mean daily insulin dose was 29 U per day. Concomitant diseases of patients in this trial included, but were not limited to , heart failure (24%), hypertension (93%), history of ischemic stroke (12%) and history of a myocardial infarction (33%). Type-1 error was controlled across multiple tests using a hierarchical testing strategy. After first use of the pen, the pen can be stored for 56 days at controlled room temperature (59°F to 86°F; 15°C to 30°C) or in a refrigerator (36°F to 46°F; 2°C to 8°C).
Particularly in endemic settings symptoms rheumatic fever order 20 mg arava with mastercard, epidemiologic linkage should be prioritized during case investigations for routine case confirmation medicine 100 years ago purchase arava 10mg online, during confirmed outbreaks and in times and places where sample collection or transportation is extremely difficult treatment trends discount 20 mg arava, such as during disasters and remote locations symptoms zoloft withdrawal generic arava 10 mg with mastercard. The interval between the two serum samples can be shorter if virus-specific IgG was not detected in the first serum sample. In the first 72 hours after rash onset, a negative result for measles IgM may be obtained from up to 30% of measles cases. Serum should be stored 48°C until shipment to laboratory, ideally no longer than 7 days. However, some countries are collecting only upper respiratory tract specimens from infants because of the difficulty of drawing blood. In some countries with very low measles prevalence, these samples can be a significant fraction of the total. Samples for antibody and viral detection should be collected at first contact with a suspected case. Whole blood can be stored at 4-8°C (never freeze whole blood) for up to 24 hours or for 6 hours at 2025°C before the serum is separated from the clotted blood through centrifugation. After this time, whole blood must be transported to a facility equipped to separate the serum in order to avoid haemolysis. Serum should be stored at 4-8°C until shipment, but ideally should not be held at 4-8°C for longer than seven days. For longer periods, such as when a delay is anticipated in shipping or testing, serum samples must be frozen at 20°C or below and transported to the testing laboratory on frozen ice packs in a sufficiently insulated container. Avoid cycles of repeated freezing and thawing, as this can have detrimental effects on the integrity of IgM antibodies. As a general rule, serum specimens should be shipped to the laboratory as soon as possible, and shipment should not be delayed for the collection of additional specimens. Collect blood by finger- or heelprick using a sterile lancet, preferably a single-use disposable lancet. Allow blood specimens that have been spotted on filter paper to air dry completely. Wrap individual cards in wax paper and place them in a sealable plastic bag with a desiccant pack. The throat swab is collected by swabbing the posterior pharynx, avoiding the tongue. If arrangements cannot be made for shipment within this timeframe, it is best to preserve the sample at -70°C. Whole urine samples may be shipped in sealed containers at 4°C, but centrifugation within 24 hours of collection is recommended. The urine is centrifuged at 500 Ч g (approximately 1500 rpm) for 510 minutes, preferably at 4°C and with the supernatant removed. Alternatively, the urine sample may be frozen at -70°C in viral transport medium and shipped on dry ice. Regardless of specimen type collected, all specimens should arrive to the lab within five days of collection, except in the case of oral fluids as noted above. If resources are sufficient or both diseases occur at similar prevalence, do measles and rubella testing in parallel, with all samples tested simultaneously for both diseases. If resources are limited or measles burden is high, do serial testing in which measles testing is done first, followed by rubella testing on samples that are negative for measles. If rubella burden is higher than measles, do the rubella testing first followed by measles testing on samples that test negative for rubella. In countries that use the fever-rash case definition and have a high burden of other fever-rash diseases (such as dengue, Zika and Chikungunya), additional testing can be integrated into the measles/rubella testing algorithm. Weigh the burden of disease and the risk of delayed diagnosis when determining the proper algorithm. Measles genotype testing and the use of named strains can help to identify the chain of transmission to which the case belongs. It is recommended that 80% of laboratory-confirmed outbreaks have their genotype determined. In some situations, extended window or whole genome sequencing may be considered to assess whether an outbreak is ongoing or the result of a new importation. False positives become more likely as the positive predictive value of IgM testing decreases as measles prevalence decreases. Epidemiological data can strengthen the argument for or against an IgM-positive result representing a true case. A second sample may need to be collected if the original sample that tested negative for measles was collected less than four days after rash onset, to ensure the case is truly negative. Figures 3a, 3b and 3c demonstrate the process for laboratory testing for suspected measles and rubella cases in elimination settings. Suspected cases in low incidence settings should be evaluated and classified after taking into consideration all laboratory and epidemiological data. Regional and global reference laboratories can provide specialized testing (such as avidity testing) and virus isolation with molecular techniques to those countries that are unable to do this in their own laboratories. If measles reinfection is suspected, consult with the regional laboratory coordinator. The equivocal or positive IgM result was obtained using a validated assay in accredited laboratory. A positive IgG result and an equivocal IgM for rubella are inconsistent with primary rubella. If acute serum was IgM positive, rubella avidity testing or evaluation of IgG titers with paired specimens may be necessary to resolve the case. If the acute serum was IgG negative, the absence of seroconversion can be demonstrated with a second serum collected 10 days post rash. However, an evaluation of IgG titers may be deemed necessary to support the IgM result. Seroconversion or demonstration of a diagnostically significant rise confirms the case. Note: failure to measure a diagnostically significant rise in titer must be interpreted with caution since the ideal timing for demonstration of a rise in titer can vary among individuals. The rise in IgG titer from a measles reinfection case is rapid and remarkably high titers in acute serum are typical. Consultation with the regional laboratory coordinator is recommended to determine if additional testing is warranted and feasible. Below is a list of general data elements for both diseases, with rubella-specific data points indicated by *. Dates of hospitalization Hospitalized because of this current feverrash diagnosis? Date of death Number of previous pregnancies* Pregnancy status* Number of weeks gestation at onset of illness* Prior evidence or date of rubella serologic immunity, or both* Number and dates of previous pregnancies and location (second administrative level or country) of these pregnancies* Pregnancy outcome, when available (normal infant, termination, infant with congenital rubella syndrome, etc. Persons who came in contact with the case in the four days prior to and four days after rash onset (potential persons exposed by the case) Transmission setting (infection acquired at home, health care setting, daycare, school, workplace, etc. Suggested age groups are < 6 months, 68 months, 911 months, 14 years, 59 years, 1014 years, 1519 years, 2024 years, 2529 years, 3044 years, 45 years, but base the age groups on the epidemiology of the disease, vaccination schedule and history of the vaccine programme. Report measles cases regularly to the next level within the Ministry of Health (at least monthly, preferably weekly), including zero reporting (reporting even when no suspected cases have been detected during the designated reporting time period). However, when disease incidence is very low or a country has achieved or nears measles elimination, the positive predictive value of the clinically compatible case definition is low and most are likely not measles. Therefore, in eliminated and near-eliminated settings, total cases are usually the sum of laboratory-confirmed and epidemiologically linked cases. All cases should be classified to determine the proportion of cases attributable to programme failure that is, cases in persons who should have been vaccinated according to the national schedule, but were not. Strive for this even in outbreaks, though it might be not feasible due to the large number of cases. A programmatically preventable measles case is a confirmed measles case for whom the vaccine was indicated based on the national immunization schedule, but who did not receive the recommended doses. A programmatically non-preventable measles case is a confirmed measles case who had been appropriately vaccinated as per the national schedule, or for whom vaccine is not routinely recommended. This distinction can help immunization programmes determine the need to improve delivery of recommended measles vaccines or change the national policy, such as changing the timing of vaccination doses.
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Beta cells make and release insulin treatment 5th toe fracture cheap arava 20mg otc, a hormone that controls the level of glucose (sugar) in the blood medicine 014 10 mg arava visa. Adult Type 1 57 Carbohydrate One of the three main classes of foods and starches that the body breaks down into glucose (a simple sugar that the body can use to feed its cells) medicine klonopin arava 20mg fast delivery. The body also uses carbohydrates to make a substance called glycogen that is stored in the liver and muscles for future use medicine on airplane purchase arava 10mg without a prescription. If the body does not have enough insulin or cannot use the insulin it has, then the body will not be able to use carbohydrates for energy the way it should. Diabetes Mellitus A disease that occurs when the body is not able to use sugar as it should. A hormone called insulin is needed for the glucose to be taken up and used by the body. Diabetes occurs when the body cannot make use of the glucose in the blood for energy because either the pancreas is not able to make enough insulin or the insulin that is available is not effective. The beta cells in areas of the pancreas, called the islets of Langerhans, usually make insulin. Diabetic Coma A severe emergency in which a person is not conscious because his or her blood glucose (sugar) is too low, he or she has hypoglycemia; if the level is too high, the person has hyperglycemia and may develop ketoacidosis. Complications of Diabetes Harmful effects that may happen when a person has diabetes. These include damage to the retina of the eye (retinopathy), the blood vessels (angiopathy), the nervous system (neuropathy), and the kidneys (nephropathy). Studies show that keeping blood glucose levels as close to the normal, non-diabetic range as possible may help prevent, slow, or delay harmful effects to the eyes, kidneys, and nerves. This may happen because of illness, taking too little insulin, or getting too little exercise. The body starts using stored fat for energy, and ketone bodies (acids) build up in include nausea and vomiting, which can lead to loss of water from the body, stomach pain, and deep and rapid breathing. Other signs are a flushed face, dry skin and mouth, a fruity breath odor, a rapid and weak pulse, and low blood pressure. If the person is not given fluids and insulin right away, ketoacidosis can lead to coma and even death. Controlled Disease A disease that has less of an effect on the body because it has been properly managed. People with diabetes can "control" the disease by staying on their diets, exercising, taking their medicine if it is needed, and monitoring their blood glucose. This care helps keep the glucose (sugar) level in the blood from becoming either too high or too low. Dietitian An expert in nutrition who helps people with special health needs plan the kind and amounts of foods to eat. A very high level of glucose (sugar) in the bloodstream causes loss of a great deal of water and the person becomes very thirsty. Endocrinologist A physician who treats people who have problems with their endocrine glands. A person can exchange, trade, or substitute a food serving in one group for another food serving in the same group. The lists put foods in six groups: (1) starch/bread, (2) meat, (3) vegetables, (4) fruit, (5) milk, and (6) fats. Within a food group, each serving has about the same amount of carbohydrate, protein, fat, and calories. The alpha cells of the pancreas (in areas called the islets of Langerhans) make glucagon when the body needs to put more sugar into the blood. An injectable form of glucagon, which can be bought in a drug store, is sometimes used to treat insulin shock. Saturated fats are solid at room temperature and come chiefly from animal food products. Some examples are butter, lard, meat fat, solid shortening, palm oil, and coconut oil. These fats tend to raise the level of cholesterol, a fat-like substance in the blood. Unsaturated fats, which include monounsaturated fats and polyunsaturated fats, are liquid at room temperature and come from plant oils such as olive, peanut, corn, cottonseed, sunflower, safflower, and soybean. Home Blood Glucose Monitoring A way a person can test how much glucose (sugar) is in the blood. Human Insulin Man-made insulins that are similar to insulin produced by your own body. Hyperglycemia Too high a level of glucose (sugar) in the blood; a sign that diabetes is out of control. It occurs when the body does not have enough insulin or cannot use the insulin it does have to turn glucose into energy. Foot Care Taking special steps to avoid foot problems such as sores, cuts, bunions, and calluses. People with diabetes have to take special care of their feet because nerve damage and reduced blood flow sometimes mean that they will have less feeling in their feet than normal. Good care includes daily examination of the feet, toes, and toenails, and choosing shoes and socks or stockings that fit well. This occurs when a person with diabetes has injected too much insulin, eaten too little food, or has exercised without extra food. A person with hypoglycemia may feel nervous, shaky, weak, or sweaty, and have a headache, blurred vision, and hunger. Taking small amounts of sugar, sweet juice, or food with sugar will usually help the person feel better within 10 to 15 minutes. Hypoglycemia Unawareness the phenomenon of hypoglycemia unawareness, known as hypoglycemia-associated autonomic failure, makes people with diabetes who have frequent blood sugar dips unaware of impending low blood sugar and unable to take proper steps (such as eating) to prevent further episodes. However, when the pregnancy ends, the blood glucose level returns to normal in about 95 percent of all cases. Adult Type 1 59 Injection Putting liquid into the body with a needle and syringe. People with diabetes inject insulin by putting the needle into the tissue under the skin (called subcutaneous). Other ways of giving medicine or nourishment by injection are to put the needle into a vein (intravenous) or into a muscle (intramuscular). The pump runs on batteries and can be worn clipped to a belt or carried in a pocket. Insulin Reaction Too low a level of glucose (sugar) in the blood; also called hypoglycemia. This occurs when a person with diabetes has injected too much insulin, eaten too little food, or exercised without extra food. The person may feel hungry, nauseated, weak, nervous, shaky, confused, and sweaty. Taking small amounts of sugar, sweet juice, or food with sugar in it will usually help the person feel better within 10 to 15 minutes. The beta cells of the pancreas (in areas called the islets of Langerhans) make the insulin. When the body cannot make enough insulin on its own, a person with diabetes must inject insulin made from other sources, i. Insulin Shock A severe condition that occurs when the level of blood glucose (sugar) drops quickly. The signs are shaking, sweating, dizziness, double vision, convulsions, and collapsing. To treat and manage the disease, the person must inject insulin, follow a diet plan, exercise daily, and test blood glucose several times a day. This type of diabetes used to be known as "juvenile diabetes," "juvenile-onset diabetes" and "ketosis-prone diabetes". Jet Injector A device that uses high pressure to propel insulin through the skin and into the body. Ketoacidosis Ketone Bodies is not enough insulin in the blood and it must break down fat cells. When the body does not have the help of insulin, the ketones build up in the blood and then "spill" over into the urine so that the body can get rid of them. The body can also rid itself of one type of ketone, called acetone, through the lungs. See: Insulin-Induced Atrophy Small dents that form on the skin when a person keeps injecting a needle in the same spot.
He/she holds his/her hands in front of him/her medicine valium discount arava 10 mg on line, where they can be seen in his/her peripheral vision 247 medications buy arava 20mg lowest price. The blocker should step in front of the spiker and jump straight up symptoms 5 days after iui purchase 10 mg arava with mastercard, shooting his/her hands over the net medications ok during pregnancy generic arava 20 mg. If the athlete can barely get the hands to the net, let him/her feel what blocking is by having him/her control block (wrists are flexed back). Ask the athlete to block jump while seeing the back of his/her hands the entire time. This will keep the hands in front of the blocker, not allowing him/her to reach up and then over the net. Show the athlete the action of jumping up and shooting the arms from the ready position, over the net. If the coach is able to hold a ball up on top of the net, have the blocker practice jumping and blocking the held ball without netting. Partner Blocking: Facing each other across the net, one athlete is the hitter and the other is the blocker. The hitter practices the approach for spiking, and the blocker works to step in front of him/her and blocks. One is the leader and the other follows trying to block wherever the leader blocks. The coach stands and hits the ball just over the top of the net for the athlete to block. As the athlete gets better, the coach can hit slightly to each side of the blocker to move him/her. Two Person Blocking: Like Coach Hitting but two blockers working together to block the coach. CoachTossing: Coach tosses for hitters to hit into the block (one or two blockers). It can be done with any part of the body but is best controlled with two arms playing the ball up in an underhand passing fashion. Both indoors and outdoors, the use of the legs and feet are legal except in high school. The defender should also watch the shoulder (which way it is facing) and the arm swing. Next the digger should stop any lateral motion and have his/her body weight forward on the balls of the feet with the knees in front of the toes. The digger should then form his/her platform by putting the hands together with the arms straight. Often the digger is trying to get any touch possible and may end up playing the ball with one arm. No matter how many arms are used, the digger should stay low to the ground and use the angle of the arms, not arm swing, to control where the ball will be dug. Should the arms be too close to the body, the dug ball will be directed straightforward and not up. This allows for quicker reactions to play a ball coming high or low at the digger. Check to see that the digger is digging the ball on the forearms, not on the hands. It is harder to control the ball with the bones of the hands than the flat forearms. Check to make sure the body weight is forward and as the hitter is about to attack, the digger should step forward. The digger has to learn to see and read the hit versus the tip and needs to move forward to play the tip up. If two hands are used, they must be connected in some fashion otherwise; the referee may call the digger for a "double contact. Overhand digging is common in doubles play since two players must cover the entire court. Just like the underhand digging described above, the athlete should be in ready position with the hand in the peripheral vision. The arms and hands drop low or rise high depending on the height the ball is traveling. To overhand dig with the hands interlaced, the hands are joined by crossing the thumbs over the back of the palms and the fingers of one hand behind the fingers of the other. If the overhand digger is going to "beach dig" the ball, then the hands are not joined but held firm to almost set the ball up. The difference between a set and a beach dig is that the beach dig requires the hands to be firmer than when setting. Have the digger practice playing up balls that are thrown at the face at a medium to slow speed. The thrower should just flex the wrists forward to throw the ball, not pull his/her arms down. Russian Pepper: Like Pepper described above but with a third person that sets the ball back to whoever dug it. Basically, two players (hitter/diggers) are facing each other about 15 feet apart. The drill begins with one hitter/digger tossing the ball to the setter who sets it back. The setter sets it back to the digger and then the digger hits it at the other digger. Brazilian Pepper: In Brazilian Pepper the middle person is the digger and the outer players are the setter/hitters. The middle person digs the ball back to who 135 ChapTer 4 Teaching Volleyball Technique: Basic Skills ever hit it at him/her. Figure 8: this drill can be done with as few as three players or as many as seven. The players enter the middle back position and shuffle step or use cross over footwork to get to the ball. The athletes should be low as they move, keeping their center of gravity low like in ready position. OvertheNetRussianPepper: Just like the drill described above but the hitter/diggers are across the net from each other. This can be done in fours with two players as setters for each of the hitter/diggers. Singles/DoublesOneContact: Like tennis this drill involves only one contact per side. The teams can be changed every play (like with King-of-the-Court or play for points rally or regular). This game can be played with lots of variations: No jumping; jumping from behind the 10-foot line only, with twos, threes or more players, no serving, but coach tosses the ball in, etc. Usually used in conjunction with defensive passing or "digging", rolling is considered a "finish" move. When on defense, the defenders must be in a defensive position ready to move their bodies in an efficient manner to prevent an attacked ball from hitting the floor within the court. However, a ball may be hit outside the comfortable reach of a player so he/she will be 136 ChapTer 4 Teaching Volleyball Technique: Basic Skills required to extend their body to attempt to make a touch on the ball to prevent a kill or point for the opponent. With much practice, the player will be more comfortable with putting his/her body out of balance and recover into balance. Technique Rolling should occur at the end of a defensive move performed by the player. The purpose of this move is to prevent injury while a player may be moving at tremendous rates toward the floor and to allow a defender to play the ball low to the ground. The inexperienced player will force and manipulate his/her body in such a way to prevent falling to the floor. An experienced and trained player will manipulate his/her body in such a way that will utilize momentum to hit the floor and recover back into a defensive position. Stepping towards the ball, the player will be required to shift weight out of balance and over the feet. As the player is falling toward the floor, arms should be outstretched in attempt to play the ball. It is important that the knee be rotated in such a way that the outside portion, not the kneecap, of the knee hit the floor to facilitate a sliding motion. That is, the athlete will roll onto his/her back and then turn over onto the hands and knees.
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