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As discussed below erectile dysfunction caused by sleep apnea discount levitra with dapoxetine 40/60 mg with amex, each of these measurements is associated with serious limitations erectile dysfunction ka desi ilaj levitra with dapoxetine 20/60mg low price. An equally important measure of the usefulness of a prediction equation is a measure of its precision erectile dysfunction more causes risk factors discount levitra with dapoxetine 40/60mg online. Since estimates of accuracy from smaller studies can be unreliable erectile dysfunction treatment pumps buy levitra with dapoxetine 40/60mg with mastercard, studies presented have at least 100 adults or 50 children impotence over 70 discount levitra with dapoxetine 20/60mg without prescription. In order to capture these valuable data the authors were contacted and asked to analyze their data and provide estimates of accuracy for this review erectile dysfunction treatment after prostate surgery buy cheap levitra with dapoxetine 40/60 mg on line. Creatinine is freely filtered by the glomerulus, but is also secreted by the proximal tubule. This overestimation is approximately 10% to 40% in normal individuals, but is greater and more unpredictable in patients with chronic kidney disease (Fig 12A). Creatinine secretion is inhibited by some common medications, for example, cimetidine and trimethoprim. Urinary clearance measurements require timed urine collections, which are difficult to obtain and often involve errors in collection. The horizontal dashed line in the left panel (A) corresponds to the lower limit for creatinine clearance (77 mL/min/1. Creatinine is mainly derived from the metabolism of creatine in muscle, and its generation is proportional to the total muscle mass. As a result, mean creatinine generation is higher in men than in women, in younger than in older individuals, and in blacks than in whites. Creatinine generation is also affected by meat intake to a certain extent, because the process of cooking meat converts a variable portion of creatine to creatinine. Evaluation 85 Though extra-renal creatinine excretion is minimal in people with normal kidney function, it is increased in patients with chronic kidney disease due to the degradation of creatinine by bacterial overgrowth in the small bowel. As much as two-thirds of total daily creatinine excretion can occur by extra-renal creatinine elimination in patients with severely reduced kidney function. In young adults, the normal level for serum creatinine concentration is approximately 1. The traditional assay for measurement of creatinine is the alkaline picrate method, which detects non-creatinine chromogens in serum (approximately 0. Urine does not contain noncreatinine chromogens, nor are these compounds retained in chronic kidney disease. Thus, historically, measured creatinine clearance has systematically underestimated true creatinine clearance. By coincidence, the difference between measured and true creatinine clearance is similar in magnitude to the clearance of creatinine due to tubular secretion. Modern autoanalyzers use serum creatinine assays with less interference by noncreatinine chromogens (for example, kinetic alkaline picrate or enzymatic methods, such as the imidohydrolase method). This calibration is not standardized, leading to variation within and across laboratories. Variation is proportionately greater at low serum creatinine values than at high values. In addition to non-creatinine chromogens, other substances may also interfere with serum creatinine assays. Therefore, serum creatinine is not an accurate index of the level of kidney function, and the level of serum creatinine alone should not be used to assess the stage of chronic kidney disease. Many studies have documented that creatinine production varies substantially across sex, age, and ethnicity. Figures 13 and 14 show that equation-based estimates perform better than serum creatinine alone. The most frequently used statistic is the correlation coefficient, which has little applicability and cannot be pooled across studies. Evaluation 89 serum creatinine, only rarely is it known how closely the serum creatinine assay reflects the true creatinine level. The abbreviated version is easy to implement since it requires only serum creatinine, age, sex, and race. The calculations can be made using available web-based and downloadable medical calculators. Evaluation 91 studies have suggested using lean body mass rather than total weight, especially for obese individuals. This equation may be superior to previous equations but the data at this point are quite limited. The difference between the constants cited in the Counahan-Barratt and the Schwartz formula has been attributed to the use of different assays to measure creatinine. The constants used in the equations differ, likely related to the different assays to measure creatinine. This example illustrates that use of both formulas can allow for estimation of kidney function, and even serum creatinine levels 1. The equation was developed in a sample of men and a correction factor for women was proposed. Evaluation of these data is limited by the use of different assays and variable calibration within creatinine assays across laboratories and over time. The serum creatinine assay in this study was calibrated to approximate true creatinine. Evaluation 95 most clinical purposes and represent a better alternative to assessing kidney function than serum creatinine alone. A 24-hour urine collection is useful for measurement of total excretion of nitrogen, electrolytes, and other substances. All four formulas reviewed provide a marked improvement over serum creatinine alone. Calculations by the laboratory, requiring only minimal clinical information, will facilitate the clinical interpretation of kidney function. The utilization of equations, some of which are complex, is much more efficient in the context of a centralized laboratory computer system than performed by individual physicians. The laboratories should mind the importance of calibrating their serum creatinine to the same level as the laboratory in which the equation was developed. In this regard, development of international standards for calibration of serum creatinine assays will be important in allowing for the accurate diagnosis of Stage 2 chronic kidney disease. There is substantial variation across laboratories in the calibration of serum creatinine, with systematic differences as large as 0. Such differences reflect a very large percentage of the serum creatinine in patients with a serum creatinine of 2. A 1987 review187 detailed 8 different existing methods to measure creatinine concentration. An analysis of College of American Pathologists survey data indicates that systematic differences in calibration of serum creatinine assays accounts for 85% of the difference between laboratories in serum creatinine. The laboratories surveyed averaged 13% bias in measurement of creatinine, larger than any other analyte examined, as well as substantial variation between laboratories in the bias. In comparison, reproducibility of the serum creatinine measures within a laboratory was much better (average coefficient of variation 8%). Laboratories should inform clinicians which creatinine assay is used in their laboratory and how it compares to measures of ``true' creatinine. A 24 hour urine collection can be used to assess urea clearance, weekly Kt/Vurea, creatinine clearance, and dietary intake of protein, sodium, potassium, and phosphorus. For details on calculations of urea clearance, weekly Kt/ Vurea, and dietary protein intake from 24 hour urine, see Part 10, Appendix 3. Evaluation 97 rates of various solutes from the ratio of solute-to-creatinine concentrations in untimed (``spot') urine samples at later times. Thus far, the accuracy of prediction equations for creatinine excretion have not been widely studied. Both methods may be limited, however, by variation in solute excretion rates during the day (as occurs with urea nitrogen in individuals with normal kidney function). At the upper range of kidney function, the role of the kidney in determining serum creatinine is of comparable magnitude to variation in other factors such as the metabolism of creatine in skeletal muscle and ingested meat in the diet. The degree of creatinine secretion can vary with time, by as much as 10% even within healthy individuals. Therefore, other markers of early kidney damage are needed to identify early decline in kidney function. However, substantial changes in secretion, generation, and extra-renal metabolism of creatinine can occur and will lead to false measures of lower degrees of progression. It is particularly difficult to use serum creatinine alone to assess progression of kidney disease in children, in whom growth and maturation lead to substantial changes in muscle mass. However, these individuals constitute only a minority of individuals with chronic kidney disease. However, limited sample size, statistical methodology, lack of information on cystatin C assay calibration, and conflicting results make the available data inadequate for recommending cystatin C measurement for widespread clinical application. Evaluation 99 nine needs to be recognized by clinical chemistry laboratories and equipment manufacturers. New methods are needed, particularly for detecting mild and moderate kidney disease, but their value in terms of bias, precision, and practicality should be well tested in large samples of subjects with and without kidney disease. The extent to which averaging multiple estimates improves precision needs further study. The amount of data in healthy individuals of different ethnicities and children is limited. This might be done in cross-sectional studies that measured these physiologic variables as well as 24-hour urine creatinine excretion. This would allow improved estimates of daily excretion of some urine solutes from measurements of solute-to-creatinine ratio in spot urine samples. In this guideline, the term ``proteinuria' refers to increased urinary excretion of albumin, other specific proteins, or total protein; ``albuminuria' refers specifically to increased urinary excretion of albumin. Guidelines for detection and monitoring of proteinuria in adults and children differ because of differences in the prevalence and type of chronic kidney disease. The most pertinent question with respect to screening for proteinuria is whether early detection of kidney disease associated with this abnormality will result in a more timely introduction of therapy that may slow the course of disease For example, in diabetic kidney disease, early detection of albuminuria appears to permit effective therapy early in the course of disease. The purpose of this guideline is to review the rationale for methods of assessment of proteinuria and to determine whether detection and monitoring of proteinuria using untimed (``spot') urine samples is as accurate as using timed (overnight or 24-hour) urine specimens. Although the basic concepts of measuring and interpreting urinary protein excretion have changed little over several decades, clinicians must now decide whether simple qualitative or more cumbersome quantitative tests are necessary and whether albumin or total protein should be measured. In clinical practice, most screening (qualitative) methods use a commercial dipstick, which measures total protein or albumin. These dipsticks, which are of course simple to use, usually afford high specificity; ie, they have relatively few false positive results, thereby creating a practical advantage 102 Part 5. However, they afford low sensitivity; ie, they may fail to detect some forms of kidney disease during the early stages, when the level of proteinuria is below the sensitivity of the test strip used. When screening tests are positive, measurement of protein excretion in a 24-hour collection has been the longstanding ``gold standard' for the quantitative evaluation of proteinuria. However, in recent years some studies have advocated that the measurement of protein excretion should be done on an overnight specimen. The rationale for measuring proteinuria in timed overnight urine collections rather than 24-hour specimens relates to the lack of consistency when hourly protein excretion rates are examined in the same individual at different times during the day. This inconsistency results from varying levels of activity and possibly other factors that are not well documented. The high intra-individual variability that ensues makes serial comparisons in individual patients very difficult unless multiple measurements are taken. This problem is particularly troublesome for individuals with orthostatic proteinuria-who may excrete more than 1 g of protein during waking hours, but less than 100 mg during sleep. Indeed, evaluation for postural (orthostatic) proteinuria requires comparison of a measurement of protein excretion in an overnight (``recumbent') collection to a daytime (``upright') collection. An alternative method for quantitative evaluation of proteinuria is measurement of the ratio of protein or albumin to creatinine in an untimed ``spot' urine specimen. These ratios correct for variations in urinary concentration due to hydration and provide a more convenient method of assessing protein and albumin excretion than that involved with timed urine collections. The issue to be explored in this section is whether this increased level of convenience can be achieved without a reduced level of precision. Based on the review of evidence accumulated over three decades, the Work Group proposes that the time has come to forego the traditional ``timed urine collections' and adopt the use of ``spot' urine measurements that compare the concentration of protein to the concentration of creatinine. The assessment of protein excretion in the urine can be accomplished by several different techniques. In addition to standard methods of measuring total protein, there are now multiple versions of immunoassays capable of detecting albumin levels at concentrations present in the majority of normal people. In general, the literature does not provide substantial information concerning the relative merits of measuring total protein versus albumin to detect and monitor kidney damage. Different guidelines for children and adults reflect differences in the prevalence of specific types of chronic kidney disease. Evaluation 103 Rationale for Using ``Spot' Urine Samples Collection of a timed urine sample is inconvenient and may be associated with errors (R, O). Twenty-four-hour urine collections may be associated with significant collection errors, largely due to improper timing and missed samples, leading to overcollections and under-collections. Timed overnight collections or shorter timed daytime collections may reduce the inconvenience of a 24-hour collection, but are still associated with collection errors.
This was not as expected based on the ``known' pathophysiology of bone mineral metabolism erectile dysfunction what is it buy levitra with dapoxetine 20/60 mg on line. The studies showing conflicting results are of similar methodological quality and sample size erectile dysfunction doctors jacksonville fl generic levitra with dapoxetine 20/60 mg online. In summary erectile dysfunction and premature ejaculation underlying causes and available treatments buy generic levitra with dapoxetine 20/60 mg online, there is not a clear relationship of the level of serum calcium to the level of kidney function over a wide range of kidney function in the reviewed studies treatment of erectile dysfunction using platelet-rich plasma generic levitra with dapoxetine 20/60mg amex. There were 21 studies relating serum phosphorus levels to kidney function reviewed for this guideline erectile dysfunction causes n treatment buy levitra with dapoxetine 20/60 mg mastercard. Fifteen studies showed the expected association of higher serum phosphorus levels with lower kidney function erectile dysfunction natural shake levitra with dapoxetine 20/60mg low price. The remaining 6 studies did not show an association of kidney function with serum phosphorus levels, although one did find a trend for increasing phosphorus levels when creatinine clearance was below 50 mL/min. There were 14 studies relating vitamin D3 (calcitriol) levels to kidney function reviewed for this guideline, with sample sizes ranging from 39 to over 200 subjects with kidney disease. Thirteen of the 14 studies evaluated 1,25 dihydroxyvitamin D levels, three of these also evaluated 24,25 dihydroxyvitamin D (2 studies) and/or 25 hydroxyvitamin D levels (3 studies), and one study evaluated only 25 hydroxyvitamin D levels. Each of the 13 studies noted that 1,25 dihydroxyvitamin D levels were lower with decreased kidney function. The two studies evaluating 24,25 dihydroxyvitamin D levels noted lower levels with lower kidney function. The four studies evaluating 25 hydroxyvitamin D levels showed conflicting results. These data confirm that 1,25 dihydroxyvitamin D levels are lower in patients with decreased kidney function. There is limited information to suggest that 24,25 dihydroxyvitamin D levels are lower in patients with decreased kidney function. The studies do not provide data on the association between level of kidney function and 25 hydroxyvitamin D levels. Bone histology is abnormal in the majority of patients with kidney failure (Table 98) (C). Six articles that related bone biopsy findings to level of kidney function among patients with chronic kidney disease not yet on dialysis were reviewed. The levels of kidney function ranged from nearly normal (creatinine clearance of 117 mL/min) to the initiation of dialysis. Among patients with kidney failure immediately prior to initiation of dialysis, 98% to 100% had abnormal bone histology, with the majority of the biopsies showing either 176 Part 6. The studies evaluating patients with varying levels of kidney function demonstrated: (1) a direct relationship between bone mineralization and kidney function415,421; (2) an inverse relationship between kidney function and bone osteoid/resorption415; or (3) a higher prevalence of abnormalities on bone biopsy (osteomalacia, resorption, osteoid) among patients with reduced kidney function. There were 4 studies of bone densitometry reviewed for this topic, which demonstrated that bone mineralization is reduced with decreased kidney function. One study presented the results as a higher prevalence of reduced bone mineral content with decreased levels of kidney function. Other studies noted a reduced bone mineral content among patients with decreased kidney function compared to controls. This is insufficient evidence to make firm statements regarding the relationship between bone density and level of kidney function. This is in part due to the lack of comparability of many of the studies given the diversity of the laboratory assays or tests for the particular abnormality. Similarly, the interpretation of bone biopsies and radiographic tests likely has a range of error, in this case related to inter-observer variability. This leads to the extrapolation of the results from other studies to such patients with variable levels of confidence for the various markers. Bone biopsy may be indicated if there is symptomatic disease or if ``aggressive' interventions such as parathyroidectomy or desferoxamine therapy are being contemplated. The applications suggested above are based on review of the available literature presented herein and on opinion. In fact, changes in the biomarkers may provide an earlier indication of worsening kidney function. Clearly, more information is needed on the abnormalities of bone mineral metabolism among patients with earlier stages of chronic kidney disease. Moreover, research on outcomes related to abnormal mineral metabolism or bone disease is lacking in both patients with mildly, as well as severely decreased kidney function. Association 179 complications, there is increasing evidence relating abnormal calcium-phosphorus metabolism and hyperparathyroidism to vascular calcification and cardiovascular complications. The relationship between levels of the available markers, and levels of kidney function, should be more accurately characterized. In addition, the relationship between such levels and kidney function should be separately studied among patients with additional risks of bone complications, that is, patients treated for prolonged periods with corticosteroids and transplant recipients. Research should also focus on the impact of interventions on levels of available markers and outcomes, specifically of interest would be comparing patients cared for by nephrologists with those not under the care of nephrologists, patients treated for some specified period of time for hyperparathyroidism compared to those not treated, and patients treated with corticosteroids compared to those never treated with such drugs. Occurrence of neuropathy is related to the level of kidney function, but not the type of kidney disease. However, there are certain causes of chronic kidney disease that also affect the central and/or peripheral nervous system. These are amyloidosis, diabetes, systemic lupus erythematosus, polyarteritis nodosa, and hepatic failure. Early uremic encephalopathy may present with fatigue, impaired memory, or concentra- 180 Part 6. With more advanced uremia delirium, visual hallucinations, disorientation, convulsions, and coma may develop. Patients may complain of pruritus, burning, muscle irritability, cramps, or weakness. Signs on examination include muscle atrophy, loss of deep tendon reflexes, poor attention span, impaired abstract thinking, abnormal or absent reflexes (in particular ankle jerk), and impaired sensation (vibratory, light touch pressure, and pain). Neuropathy is present in up to 65% of patients at the initiation of dialysis438,439; thus, it must begin to develop during an earlier phase of kidney disease. No articles were found that specifically related the presence of neuropathy to other outcomes among patients with chronic kidney disease. However, it is self-evident that impaired cognition and sleep, dysesthesias, and impaired autonomic function would at least lead to reduced quality of life and inability to function normally. If the neuropathy leads to skin ulcers, then certainly this would result in objective morbidity and potentially mortality. Several of the articles reviewed note that the majority of patients who have abnormalities in tests of nervous system function are asymptomatic. Most studies demonstrated a relationship between kidney function and the particular marker of neuropathy. However, several studies only compared the particular marker with the normal or reference standard for the test or compared grouped data on patients with kidney disease with controls or patients on dialysis/transplant without providing data at various levels of kidney function. The studies had sample sizes ranging from 40 to 210 subjects, with 29 to 72 patients with decreased kidney function not yet on dialysis. Only one study was found that evaluated memory and cognition among patients with decreased kidney function prior to the availability of erythropoietin. Each of these test measures was significantly lower among patients with decreased kidney function, correlated with level of dysfunction, and was improved to varying degrees among patients on dialysis and to a greater degree among patients with a kidney transplant. Only three studies were found that objectively evaluated autonomic function among patients with kidney disease. These studies had between 42 and 123 subjects and between 21 and 67 patients with decreased kidney function not yet on dialysis. Each of these studies noted that autonomic function was impaired in more than 50% of patients with chronic kidney disease; however, only one of them found an association between level of kidney function and measures of autonomic nerve function. Symptoms or clinical signs of peripheral neuropathy were evaluated or mentioned in four of the six studies of peripheral neuropathy reviewed for this guideline. More articles than were reviewed were found with the literature search, but were not exhaustively reviewed as preliminary review suggested the lack of or inability to extract the necessary information. This may have led to the omission of some articles that may have provided further information. These guidelines are limited by the inability to provide a definitive quantitative or semi-quantitative assessment of the relationship between level of kidney function and markers of neuropathy. This is in part due to the dearth of studies, the use of different measures of kidney function, the limited presentation of methods, and the failure to present adequate correlation data. In particular, there was extremely limited information on cognitive function and symptoms of neuropathy. Lastly, many of the studies involved only a limited number of patients with mildly to moderately decreased kidney function, and two of the studies were limited to diabetics, confounding the results with the presence of diabetic neuropathy. More information on neuropathy among patients with chronic kidney disease with earlier stages of chronic kidney disease may provide other means to follow progression of chronic kidney disease. Association 185 kidney disease and a relationship to kidney function, treatments to delay its progression could be considered. The relationship between subjective and objective measures of neuropathy, and levels of kidney function, should be more accurately characterized. In addition, the relationship between neuropathy and kidney function should be separately studied among patients with additional risks of neuropathy, such as diabetics and patients with amyloidosis. The purpose of this guideline is to identify stages and complications of kidney disease that place adult patients at greater risk for reduced quality of life. This guideline is not intended to cover all the quality of life concerns that apply to children and adolescents, nor is it intended to recommend interventions to improve quality of life in any age group. For the purpose of this guideline, concepts that embody pertinent components of quality of life will be referred to as ``functioning and wellbeing. To improve functioning and well-being, patients must be referred sooner and complications and comorbid conditions must be managed appropriately. This guideline describes the association between the level of kidney function and domains of functioning and well-being in patients with chronic kidney disease. One must analyze the full continuum of stages of chronic kidney disease to understand the risks for compromised functioning and well-being. Armed with this knowledge, clinicians can more quickly identify stages of chronic kidney disease at which deficits are likely to 186 Part 6. Difficulties in measuring this poorly understood concept have led researchers in the articles reviewed to study several variables using different methods and instruments (Table 102). Use of different instruments has impeded comparing findings, interpreting results, and drawing conclusions. Strength of Evidence Indices of functioning and well-being are impaired in chronic kidney disease (R). Impaired functioning and wellbeing in dialysis patients is linked to increased risk of death and hospitalization while improvement in scores has been associated with better outcomes. Low income and low education were associated with greater impairments in functioning and well-being in patients with chronic kidney disease. Hypertension, diabetes with angina, prior cardiac infarction,460 osteoporosis, bone fractures,461 and malnutrition462 have been shown to impair functioning and wellbeing in those with no known kidney disease. Among veterans with diabetes, neuropathy and kidney disease have been associated with the greatest decrease in functioning and well-being. Data from cross-sectional studies and baseline data from longitudinal studies were reviewed to assess the relationship between level of kidney function and level of functioning and well-being. Populations studied include those with decreased kidney function, including those with functioning transplants, and dialysis patients when compared with healthy subjects or kidney transplant recipients. Reduced kidney function is associated with increasing symptoms such as tiring easily, weakness, low energy, cramps, bruising, bad tasting mouth, hiccoughs, and poor odor perception. This is true in patients with native kidney disease and those with kidney transplants. Diabetic dialysis and transplant patients are more likely to report poor health than dialysis or transplant patients who do not have diabetes. In transplant recipients, reduced kidney function is also associated with poorer physical function scores. Dialysis patients report greater physical dysfunction than transplant recipients and diabetic dialysis and transplant patients are more likely to report physical dysfunction than those patients who do not have diabetes. Reduced kidney function is associated with poorer psychosocial functioning, higher anxiety, higher distress, decreased sense of well-being, higher depression, and negative health perception. Depressed patients are more likely to report poor life satisfaction, irrespective of kidney function. In elderly Mexican Americans, kidney disease has been found to be predictive of depressive symptoms. More dialysis patients report their health limits work and other activities than those with functioning transplants. Dialysis and transplant patients with diabetes are more likely to report difficulty working than dialysis and transplant patients without diabetes. Reduced kidney function is associated with reduced social activity, social functioning, and social interaction. Dialysis patients report fewer neighborhood acquaintances, social contacts, and worse social well-being than healthy individuals while transplant recipients report higher social function and social 192 Part 6. Diabetics on dialysis or with transplants are more likely to report problems with social interaction than nondiabetic patients. Level of perceived social support in chronic kidney disease is not associated with the level of kidney function. Medication usage was not reported even if medications (eg, anti-depressants) could affect outcomes. Three studies reported differences between groups of very unequal sizes and one reported percentages but did not report whether observed differences were statistically significant. Historically, there has been no ``gold standard' definition for quality of life or functioning and well-being.
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Published every four years since 1997, Global Trends assesses the key trends and uncertainties that will shape the strategic environment for the United States during the next two decades. Global Trends is designed to provide an analytic framework for policymakers early in each administration as they craft national security strategy and navigate an uncertain future. The goal is not to offer a specific prediction of the world in 2040; instead, our intent is to help policymakers and citizens see what may lie beyond the horizon and prepare for an array of possible futures. Each edition of Global Trends is a unique undertaking, as its authors on the National Intelligence Council develop a methodology and formulate the analysis. This process involved numerous steps: examining and evaluating previous editions of Global Trends for lessons learned; research and discovery involving widespread consultations, data collection, and commissioned research; synthesizing, outlining, and drafting; and soliciting internal and external feedback to revise and sharpen the analysis. A central component of the project has been our conversations with the world outside our security gates. We benefited greatly from ongoing conversations with esteemed academics and researchers across a range of disciplines, anchoring our study in the latest theories and data. These discussions offered us new ideas and expertise, challenged our assumptions, and helped us to identify and understand our biases and blind spots. One of the key challenges with a project of this breadth and magnitude is how to organize all the analysis into a story that is coherent, integrated, and forward looking. We constructed this report around two central organizing principles: identifying and assessing broad forces that are shaping the future strategic environment, and then exploring how populations and leaders will act on and respond to the forces. Based on those organizing principles, we built the analysis in three general sections. First, we explore structural forces in four core areas: demographics, environment, economics, and technology. The second section examines how these structural forces interact and intersect with other factors to affect emerging dynamics at three levels of analysis: individuals and society, states, and the international system. The analysis in this section involves a higher degree of uncertainty because of the variability of human choices that will be made in the future. We focus on identifying and describing the key emerging dynamics at each level, including what is driving them and how they might evolve over time. Finally, the third section identifies several key uncertainties and uses these to create five future scenarios for the world in 2040. These scenarios are not intended to be predictions but to widen the aperture as to the possibilities, exploring various combinations of how the structural forces, emerging dynamics, and key uncertainties could play out. When exploring the long-term future, another challenge is choosing which issues to cover and emphasize, and which ones to leave out. We focused on global, long-term trends and dynamics that are likely to shape communities, states, and the international system for decades and to present them in a broader context. We offer this analysis with humility, knowing that invariably the future will unfold in ways that we have not foreseen. Although Global Trends is necessarily more speculative than most intelligence assessments, we rely on the fundamentals of our analytic tradecraft: we construct arguments that are grounded in data and appropriately caveated; we show our work and explain what we know and do not know; we consider alternative hypotheses and how we could be wrong; and we do not advocate policy positions or preferences. We are proud to publish this report publicly for audiences around the world to read and consider. We hope that it serves as a useful resource and provokes a conversation about our collective future. Finally, a note of gratitude to colleagues on the National Intelligence Council and the wider Intelligence Community who joined in this journey to understand our world, explore the future, and draft this report. These challenges will repeatedly test the resilience and adaptability of communities, states, and the international system, often exceeding the capacity of existing systems and models. This looming disequilibrium between existing and future challenges and the ability of institutions and systems to respond is likely to grow and produce greater contestation at every level. In this more contested world, communities are increasingly fractured as people seek security with like-minded groups based on established and newly prominent identities; states of all types and in all regions are struggling to meet the needs and expectations of more connected, more urban, and more empowered populations; and the international system is more competitive-shaped in part by challenges from a rising China-and at greater risk of conflict as states and nonstate actors exploit new sources of power and erode longstanding norms and institutions that have provided some stability in past decades. These dynamics are not fixed in perpetuity, however, and we envision a variety of plausible scenarios for the world of 2040-from a democratic renaissance to a transformation in global cooperation spurred by shared tragedy-depending on how these dynamics interact and human choices along the way. Paradoxically, as the world has grown more connected through communications technology, trade, and the movement of people, that very connectivity has divided and fragmented people and countries. The hyperconnected information environment, greater urbanization, and interdependent economies mean that most aspects of daily life, including finances, health, and housing, will be more connected all the time. The Internet of Things encompassed 10 billion devices in 2018 and is projected to reach 64 billion by 2025 and possibly many trillions by 2040, all monitored in real time. In turn, this connectivity will help produce new efficiencies, conveniences, and advances in living standards. However, it will also create and exacerbate tensions at all levels, from societies divided over core values and goals to regimes that employ digital repression to control populations. As these connections deepen and spread, they are likely to grow increasingly fragmented along national, cultural, or political preferences. In addition, people are likely to gravitate to information silos of people who share similar views, reinforcing beliefs and understanding of the truth. Meanwhile, globalization is likely to endure but transform as economic and production networks shift and diversify. All together, these forces portend a world that is both inextricably bound by connectivity and fragmenting in different directions. These challenges-which often lack a direct human agent or perpetrator-will produce widespread strains on states and societies as well as shocks that could be catastrophic. The effects of climate change and environmental degradation are likely to exacerbate food and water insecurity for poor countries, increase migration, precipitate new health challenges, and contribute to biodiversity losses. Novel technologies will appear and diffuse faster and faster, disrupting jobs, industries, communities, the nature of power, and what it means to be human. Continued pressure for global migration-as of 2020 more than 270 million persons were living in a country to which they have migrated, 100 million more than in 2000-will strain both origin and destination countries to manage the flow and effects. These challenges will intersect and cascade, including in ways that are difficult to anticipate. National security will require not only defending against armies and arsenals but also withstanding and adapting to these shared global challenges. There is an increasing mismatch at all levels between challenges and needs with the systems and organizations to deal with them. The international system-including the organizations, alliances, rules, and norms-is poorly set up to address the compounding global challenges facing populations. Within states and societies, there is likely to be a persistent and growing gap between what people demand and what governments and corporations can deliver. As a result of these disequilibriums, old orders-from institutions to norms to types of governance-are strained and in some cases, eroding. And actors at every level are struggling to agree on new models for how to structure civilization. This contestation is playing out across domains from information and the media to trade and technological innovations. Climate change, for example, will force almost all states and societies to adapt to a warmer planet. Some measures are as inexpensive and simple as restoring mangrove forests or increasing rainwater storage; others are as complex as building massive sea walls and planning for the relocation of large populations. Countries with highly aged populations like China, Japan, and South Korea, as well as Europe, will face constraints on economic growth in the absence of adaptive strategies, such as automation and increased immigration. The most effective states are likely to be those that can build societal consensus and trust toward collective action on adaptation and harness the relative expertise, capabilities, and relationships of nonstate actors to complement state capacity. This encompasses rising tensions, division, and competition in societies, states, and at the international level. Many societies are increasingly divided among identity affiliations and at risk of greater fracturing. Relationships between societies and governments will be under persistent strain as states struggle to meet rising demands from populations. As a result, politics within states are likely to grow more volatile and contentious, and no region, ideology, or governance system seems immune or to have the answers. Decades of progress in education, health, and poverty reduction will be difficult to build on or even sustain. First, we examine structural forces in demographics, environment, economics, and technology that shape the contours of our future world. Second, we analyze how these structural forces and other factors-combined with human responses-affect emerging dynamics in societies, states, and the international system. Newly prominent identities, resurgent established allegiances, and a siloed information environment are exposing fault lines within communities and states, undermining civic nationalism, and increasing volatility. Rapid technological advancements fostered by public-private partnerships in the United States and other democratic societies are transforming the global economy, raising incomes, and improving the quality of life for millions around the globe. In contrast, years of increasing societal controls and monitoring in China and Russia have stifled innovation. The burdens will be unevenly distributed, heightening competition, contributing to instability, straining military readiness, and encouraging political movements. Calls for more planning and regulation will intensify, particularly of large platform, e-commerce corporations. A growing gap between public demands and what governments can deliver will raise tensions, increase political volatility, and threaten democracy. The United States and China will have the greatest influence on global dynamics, forcing starker choices on other actors, increasing jockeying over global norms, rules, and institutions, and heightening the risk of interstate conflict. The risk of major war is low, and international cooperation and technological innovation make global problems manageable. Information flows within separate cyber-sovereign enclaves, supply chains are reoriented, and international trade is disrupted. Richer countries shift to help poorer ones manage the crisis and then transition to low carbon economies through broad aid programs and transfers of advanced energy technologies. In some areas, these trends are becoming more intense, such as changes in our climate, the concentration of people in urban areas, and the emergence of new technologies. Trends in other areas are more uncertain-gains in human development and economic growth are likely to slow and may even reverse in some areas, although a mix of factors could change this trajectory. The convergence of these trends will offer opportunities for innovation but also will leave some communities and states struggling to cope and adapt. The most certain trends during the next 20 years will be major demographic shifts as global population growth slows and the world rapidly ages. Some developed and emerging economies, including in Europe and East Asia, will grow older faster and face contracting populations, weighing on economic growth. In contrast, some developing countries in Latin America, South Asia, and the Middle East and North Africa benefit from larger working-age populations, offering opportunities for a demographic dividend if coupled with improvements in infrastructure and skills. Human development, including health, education, and household prosperity, has made historic improvements in every region during the past few decades. These factors will challenge governments seeking to provide the education and infrastructure needed to improve the productivity of their growing urban middle classes in a 21st century economy. As some countries rise to these challenges and others fall short, shifting global demographic trends almost certainly will aggravate disparities in economic opportunity within and between countries during the next two decades as well as create more pressure for and disputes over migration. In the environment, the physical effects of climate change are likely to intensify during the next two decades, especially in the 2030s. The impact will disproportionately fall on the developing world and poorer regions and intersect with environmental degradation to create new vulnerabilities and exacerbate existing risks to economic prosperity, food, water, health, and energy security. Governments, societies, and the private sector are likely to expand adaptation and resilience measures to manage existing threats, but these measures are unlikely to be evenly distributed, leaving some populations behind. Debates will grow over how and how quickly to reach net zero greenhouse gas emissions. During the next two decades, several global economic trends, including rising national debt, a more complex and fragmented trading environment, a shift in trade, and new employment disruptions are likely to shape conditions within and between states. Many governments may find they have reduced flexibility as they navigate greater debt burdens, diverse trading rules, and a broader array of powerful state and corporate actors exerting influence. Large platform corporations-which provide online markets for large numbers of buyers and seller-could drive continued trade globalization and help smaller firms grow and gain access to international markets. These powerful firms are likely to try to exert influence in political and social arenas, efforts that may lead governments to impose new restrictions. Asian economies appear poised to continue decades of growth through at least 2030, although potentially slower. Productivity growth remains a key variable; an increase in the rate of growth could alleviate Image / Bigstock many economic, human development, and other challenges. Technology will offer the potential to mitigate problems, such as climate change and disease, and to create new challenges, such as job displacement. Technologies are being invented, used, spread, and then discarded at ever increasing speeds around the world, and new centers of innovation are emerging. During the next two decades, the pace and reach of technological developments are likely to increase ever faster, transforming a range of human experiences and capabilities while also creating new tensions and disruptions within and between societies, industries, and states. State and nonstate rivals will vie for leadership and dominance in science and technology with potentially cascading risks and implications for economic, military, and societal security. These interactions are also likely to produce greater contestation at all levels than has been seen since the end of the Cold War, reflecting differing ideologies as well as contrasting views on the most effective way to organize society and tackle emerging challenges. Within societies, there is increasing fragmentation and contestation over economic, cultural, and political issues. People are gravitating to familiar and like-minded groups for community and security, including ethnic, religious, and cultural identities as well as groupings around interests and causes, such as environmentalism. The combination of newly prominent and diverse identity allegiances and a more siloed information environment is exposing and aggravating fault lines within states, undermining civic nationalism, and increasing volatility. At the state level, the relationships between societies and their governments in every region are likely to face persistent strains and tensions because of a growing mismatch between what publics need and expect and what governments can and will deliver. Populations in every region are increasingly equipped with the tools, capacity, and incentive to agitate for their preferred social and political goals and to place more demands on their governments to find solutions.
Response accommodations may enable students to use different ways to complete assignments impotence from diabetes cheap levitra with dapoxetine 40/60 mg with visa, tests and activities impotence after prostate surgery generic 20/60 mg levitra with dapoxetine visa. Alternate Response Modes Students with disabilities unable to respond in standard ways may need to use an alternate response mode impotence for erectile dysfunction causes buy levitra with dapoxetine 20/60mg without prescription. This may include students who have sensory or language impairments erectile dysfunction zyprexa purchase 20/60mg levitra with dapoxetine visa, as well as students who have motor impairments that result in difficulty with handwriting or speaking erectile dysfunction how can a woman help purchase levitra with dapoxetine 20/60mg line. A scribe writes down or records what a student dictates erectile dysfunction doctors albany ny buy cheap levitra with dapoxetine 40/60mg on line, whether through speech, sign language, a communication system or device, or by pointing. A word processor or computer may be used by a student who has difficulty with handwriting. Speech-to-text conversion or voice recognition software can be used to dictate text or give commands to the computer. In some testing situations, the spelling and grammar check feature must be turned off (Shyyan et al. Word prediction software provides a list of choices based on words previously typed. Portable note-taking devices are small, lightweight devices equipped with a braille or standard keyboard for input. Some devices have additional features, such as a calculator and calendar, and can be connected to the Internet or personal computer to exchange files or print. Applications can record audio notes and allow the user to enter written notes with a keyboard on smartphones and tablets (Kendrick, 2011, July; American Foundation for the Blind, 2017b). Voice recorders are often included in apps used in smartphones, tablets or computers. Voice recognition software converts speech to text, so the student can use voice to dictate text and give commands to the computer. Sign language is used for communication, primarily by students who are deaf or hard of hearing. American Sign Language, manually coded English and finger spelling are different types of sign language. Students may need an interpreter when they communicate with persons who do not know sign language. Cued speech (language) transliterators are professionals that facilitate communication between individuals who use spoken language and those who use cued speech. Response Supports Students use response supports to facilitate their use of standard methods for expression. Supports for Handwriting Students with disabilities who write illegibly may have problems with letter formation, letter size, letter and word spacing, and writing on or between the lines. The occupational therapist can also determine the need for specialized furniture or adapted tools. Pencils, markers or crayons of different diameters, pencils with softer lead and softer crayons may be used by students who have difficulty grasping or controlling writing implements. Mechanical pencils and nonabrasive erasers help students who use excessive pressure when writing (Rein, 1997/2001). High-contrast writing tools, such as markers, felt-tipped pens and soft-lead pencils, help students with visual impairments read their own writing. Pencil or pen grips enlarge or adapt the shape of standard writing tools to correctly position the fingers and hand when writing. They include triangular or pear-shaped grips and grips with indentations for fingers (Rein, 1997/2001). Some spacers feature an arrow for directionality and a window for tracking when reading (Rein, 1997/2001). Handwriting guides or templates help students stay within a defined writing space. The student lays the guide on top of a regular sheet of paper with a cutout area for writing that exposes the space between the lines (Rein, 1997/2001). Alphabet strips provide a model for students to guide letter formation in manuscript or cursive style. The paper may have wider lines, colored or shaded areas between the lines, colored lines or raised lines as tactile cues. Gridded paper can be used to help students organize numbers for mathematics computation, allowing one digit per cell (Rein, 1997/2001). Visual cues can be added to standard writing paper, such as highlighting the left margin or drawing lines for margins. A paper can be divided into sections by drawing lines, folding or covering parts of the text. Paper stabilizers position paper at an appropriate place on the desk and keep it from moving. Nonslip mats or rubberized netting will stabilize a binder or clipboard (Rein, 1997/2001). Physical support or positioning may be needed to stabilize students who have a physical impairment. Students with limited mobility may also need assistance manipulating instructional materials, objects and equipment. As an alternative, the student can use erasable markers on clear sheets of acetate overlaying the text. The student may need two copies of a worksheet-one for a draft and one for the final copy. Supports for Written Expression Students with disabilities may have difficulty planning and drafting writing because they have insufficient understanding of text structure, topics or audience. Some students have difficulty with linguistic knowledge, including spelling, vocabulary, sentence structure and mechanics. Dictionaries and thesauruses can assist the student with word choice when writing. Some devices include electronic or talking dictionaries that check spelling and grammar usage as well as word meaning. Strategies, templates, checklists and grammar rules can be printed on personal cue cards or posted in the classroom as quick reference guides. An individualized spelling list or a personal dictionary of frequently used vocabulary may help the student with word choice when writing. Talking spelling and grammar devices allow the student to enter an approximate spelling or usage of the word and then see and hear the correct version. Graphic organizers and outlining help students identify or create a structure for organizing information in patterns or diagrams. Students can use paper-based graphic organizers or software for planning reports, essays and content maps. Supports for Oral Expression Students with disabilities who have difficulty using spoken language may need accommodations to get their message across. Increased wait time may provide students the opportunity to think about what they want to say and how they will say it. Use of visual images can help students convey their spoken message through pictures, drawings or other graphics. They may struggle with mathematical symbols, how to solve problems or apply abstract concepts. Some students with disabilities require concrete materials or visual representations as an accommodation. Devices include the calculator, abacus, geoboard or special software (Math Windows and Graphic Aid for Mathematics). It is important to determine whether the use of a calculation device is a matter of convenience or a necessary accommodation. For example, if students are learning how to subtract, a calculator does not show the steps for regrouping. On the other hand, if students are learning problem-solving skills that involve subtraction. Adapted calculators are available with large keys or voice output (talking calculators) for students with visual impairments. In testing situations, calculator use may be limited for certain items or grade levels. They include raised line or braille-embossed number line, tactile graphic forms, geoboard, manipulatives for counting and number systems, tactile and braille rulers and protractors, and clocks with braille numerals (Texas School for the Blind and Visually Impaired, n. The use of raised lines or rough surfaces on materials can provide tactile feedback to help students identify the image or object. A chart of math facts may be used by students who are not fluent with basic math facts. Concrete materials and manipulatives are used by students to represent mathematical concepts and procedures. Visual representations display simple and complex mathematical concepts and procedures using visuals, such as diagrams, flowcharts and computer animations. Specialized mathematical image descriptions may be needed by students to increase accessibility of instructional materials that include graphs, math diagrams, geometric figures, and equations and expressions. Some software programs can translate mathematical formulas into speech (Diagram Center, n. Planning guides with a list of steps or flowchart can help students recall what to do when solving math problems. Special paper, including gridded or graph paper, can help students line up digits for computation. Setting Accommodations Setting accommodations involve changes in the location or conditions of the educational environment. Accommodations can address accessibility issues, behavior and attention, and organization of space and materials. Students who use accommodations that distract other students, such as a reader or scribe, may also need setting accommodations. Students may need an accessible location, specific room conditions or special equipment as a result of their disability. Students should be able to access all parts of the building, including classrooms, restrooms, cafeteria, media center and school grounds. Many buildings are made accessible because they are equipped with nonslip surfaces, guide rails, ramps, elevators and automatic doors. Accessible workstations include adjustable desks and tables for students who use mobility aids, such as a wheelchair. The specific location will depend on the needs of the student and the typical activities used in the classroom. Special lighting or light filters may be needed by a student with eye strain or fatigue. Acoustical treatments diminish background noise and distractions in the classroom. Window treatments, rugs or carpets, and soft materials on the walls can reduce noise. Noisy equipment, including light fixtures, should be turned off when not in use (American Speech-Language-Hearing Association, 2017b, 2017c). Assignments and assessments administered in a familiar place or by a familiar person may be needed for instruction and testing. Supports for Behavior and Attention Students with disabilities who have difficulty maintaining attention and effort may need accommodations. Students may require positive behavioral supports or a specialized behavior management system that includes monitoring of behavior in school with regular reports to the parents. Rules should be clearly defined and articulated to the student and may be integrated with the individual behavior plan. Regular procedures and predictable routines for beginning and ending classes can be implemented. The student should be seated away from windows, heating or cooling vents, doors, resource areas, and other disruptions. Noise buffers can reduce auditory distractions and help the student concentrate and maintain focus. Examples include headphones, earphones and earplugs, white noise (environmental sound machines), and approved music. Small-group or other special grouping arrangements may be required for students who need additional personal attention and support. The size of the group (teacher-to-pupil ratio) must be specified in the description of the accommodation. Other students have difficulty controlling behaviors that may distract other students. Some students may need to move in the classroom without disrupting other students. Organization of Space and Materials Students with disabilities may have trouble managing their own space and materials in the classroom. Diagrams that show how to organize books and materials can be posted inside the locker for reference. Binders with color-coded dividers or folders can keep materials for each subject separate. Access to learning resources and instructional materials outside of class can be provided. Students may need scheduling accommodations to address issues related to effort, rate of performance, attention, and their own ability to monitor and manage time. Time Allocation Changes in the amount of time or the way the time is organized for activities can be provided as an accommodation.