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If the patient does not improve in 4 days symptoms 0f food poisoning order 200mcg cytotec visa, open lung biopsy is the procedure of choice symptoms after conception cheap 200 mcg cytotec visa. In patients with pulmonary infiltrates who are afebrile treatment rosacea buy 100 mcg cytotec mastercard, heart failure and multiple pulmonary emboli are in the differential diagnosis symptoms 4dp5dt buy cheap cytotec 200 mcg on line. This compliin the inferior mesenteric vein (arrow) and bowel wall with cation has also been seen in patients with other forms of pneumatosis intestinalis. Rapid institution of broad-spectrum antibisupportive, with reduction in doses of immunosuppres489 otics and nasogastric suction may reverse the process. No antiviral therapy is approved, Surgical intervention should be considered if no although cidofovir is being tested. Symptoms include gross hematuria, frequency, histamine H1 and H2 receptor antagonists and glucodysuria, burning, urgency, incontinence, and nocturia. In these cases, retreatment may be attempted 2-mercaptoethanesulfonate (mesna) detoxifies the metabowith care, but use of alternative agents may be required. Expert Rev Anticancer Ther 7:233, 2007 effective, irrigation of the bladder with a 0. J Clin Oncol 23:5211, extreme cases, ligation of the hypogastric arteries, urinary 2005 diversion, or cystectomy may be necessary. Treatment of viral hemorrhagic cystitis is largely induced hypersensitivity reactions. Such clinical laboratories may continue to report values in variables include the population studied, the duration “conventional” units. Therefore, both systems are proand means of specimen transport, laboratory methods vided in the Appendix. The dual system is also used in and instrumentation, and even the type of container the text except for (1) those instances in which the used for the collection of the specimen. The reference numbers remain the same but only the terminology is or “normal” ranges given in this appendix may therefore changed. However, there is a time lag in attainment of equilibrium, and cerebrospinal levels of plasma constituents that can fiuctuate rapidly. Source: From Weyman A: Principles and Practice of Echocardiography, 2d ed, Philadelphia, Lea & Febiger, 1994. Textbook of Clinical Chemistry and Molecular Diagnostics, 4th ed, Weekly clinicopathological exercises. He denies fevers and chills and clinical scenarios and community-acquired pneuhas not had any leg swelling. Heavy alcohol use: atypical pathogens and Staphylococcus uration is 94% on room air. Referral for thoracoscopy with stapling of blebs and imately 1 teaspoon of blood every day for the past 4 pleural abrasion days. Urinalysis shows 2+ protein and pholipid syndrome with prior pulmonary embolism red blood cell casts. The presence of autoantibodies and has been nonadherent to her anticoagulation directed against which of the following is most recently. Harrison’s Principles of Internal Medicine Self-Assessment and Board Review, 17th ed. The cardiovascular examinaA thoracentesis is performed, with the following 2 tion shows a regular tachycardia without murmurs, results: rubs, or gallops. On extremity examination, there is swelling of Appearance Viscous, cloudy her left thigh with a positive Homan’s sign. What 2 is the next best step in management of this Bacterial cultures are sent, but the results are not curpatientfi Which characteristic of the pleural fiuid is most suggestive that the patient will require A. A 63-year-old man with a long history of cigation test results, pick those that are the most rette smoking comes to see you for a 4-month likely finding in each of the following respiratory history of progressive shortness of breath and dysdisorders: pnea on exertion. A 52-year-old woman presents with a communityshows diffuse bilateral inspiratory crackles. Acute interstitial pneumonitis free-fiowing pleural effusion on the right and also B. Which of the following statements about this concell count, 230/fiL (85% lymphocytes, 10% neudition is truefi Persons who live at high altitudes are not at risk for following tests is most likely to yield the cause of this disorder even when they return to a high altitude the pleural effusionfi Thoracoscopic biopsy of the pleura children, and after 2 years of unprotected intercourse, his wife has not achieved pregnancy. She smokes a pack of cigarettes daily constriction and has done so since 18 years of age. Acts at fi1-adrenergic receptors and dopaminergic examination, she appears dyspneic at rest. Her vital receptors to increase cardiac contractility and heart signs are blood pressure, 138/86 mmHg; heart rate. Acts at fi1and, to a lesser extent, fi2-adrenergic recep2 dullness to percussion halfway up her right lung field tors to increase cardiac contractility, heart rate, and with decreased tactile fremitus. A chest radiograph shows a large heart rate, cardiac contractility, and vasoconstriction 516 Review and Self-Assessment 19. Obstructive sleep apnea plaining of chills for the past few days; no further hisD. Periodic limb movement disorder of sleep tory is available from the nursing home staff. The emergency responders on exertion, low-grade fevers, and weight loss over 6 were able to appreciate a faint pulse and obtained a months. He also is complaining of a primarily dry blood pressure of 91/49 mmHg and a heart rate of cough, although occasionally he coughs up a thick, 120 bpm. On physical examination, moaning and obtunded, localizes to pain, and has fiat the patient appears dyspneic with minimal exertion. Oxygen is placed, specimens for initial laboratory testing are saturation is 91% on room air at rest. Faint basilar sent off, and an electrocardiogram and chest x-ray are crackles are heard. An anesthesiologist has been called to the has polyclonal hypergammaglobulinemia and a hematbedside and is assessing the patient’s airway. Infuse hypertonic saline to increase the rate of vascuwith bronchoalveolar lavage. The first sign of hypovolemic shock is mental He was found unresponsive in his bed, and 911 was obtundation. She is hypotensive with a blood across the precordial leads, and he is taken emergently pressure of 84/60 mmHg and a heart rate of 80 bpm. An arterand stent placement, he is transferred to the coronary ial blood gas is performed showing the following: care unit. His radial pulse is thready, extremities are cool, the patient’s arterial blood gasfi The patient is hypoxic because of hypoventilation and asks what you would like to do next. The patient is hypoxic because of hypoventilation characteristics of this patient’s conditionfi Diminished protein S level cantly limited because of her fatigue, and she has sigE. During her evaluation, laboratory analysis reveals sodium, 137 meq/L; potassium, 29. A 52-year-old man presents with crushing substernal out of state and rode in a car for about 9 h each chest pain. Prednisone and cyclophosphamide blood pressure, 98/60 mmHg; heart rate, 114 bpm; D. A 68-year-old man presents for evaluation of dyspThere is pain in the right calf with dorsifiexion of nea on exertion.
Factors affecting Reportable Diseases in Ontario (1991-2016) 73 Rubella medications you can take during pregnancy generic cytotec 100 mcg fast delivery, congenital syndrome Figure 35 medicine the 1975 order cytotec 100 mcg without a prescription. An imported case is one whose mother was outside Canada during the period when she may have had exposure to symptoms queasy stomach purchase cheap cytotec line rubella that affected her pregnancy (from 23 days prior to rust treatment order cytotec line conception or until week 24 of gestation). Factors affecting Reportable Diseases in Ontario (1991-2016) 75 Salmonellosis Figure 36. Serotype information for Salmonella should be considered when conducting an epidemiological analysis. Enteritidis cases across Canada, 531 of which were from Ontario, linked to the consumption of shredded cheese 63 in Schneider luncheon snacks. This increase in reported cases was due in part to: o A national investigation of several Salmonella serotypes, with 35 reported cases from Ontario, linked to the consumption of various chia seed products. Typhimurium cases in Ontario, most of whom reported being exposed to reptiles and/or rodents. The cases were part of a national investigation and originated from an increase that began in 2012. The definitive source of this outbreak 9 was not identified, however, chicken was suspected. Factors affecting Reportable Diseases in Ontario (1991-2016) 77 o An increase in cases of S. Store-bought, frozen, processed, breaded chicken was identified as a risk factor that likely contributed to the 9 observed increase. Factors affecting Reportable Diseases in Ontario (1991-2016) 78 Shigellosis Figure 37. Factors affecting Reportable Diseases in Ontario (1991-2016) 79 Syphilis Figure 38. Factors affecting Reportable Diseases in Ontario (1991-2016) 81 Tetanus Figure 39. Factors affecting Reportable Diseases in Ontario (1991-2016) 82 1981 fi A combined tetanus and diphtheria (Td) vaccine was added to the publicly-funded program as booster doses given at 14-16 years and every 10 years for adults. Factors affecting Reportable Diseases in Ontario (1991-2016) 83 Trichinosis Figure 40. Factors affecting Reportable Diseases in Ontario (1991-2016) 84 Tuberculosis Figure 41. Factors affecting Reportable Diseases in Ontario (1991-2016) 86 Tularemia Figure 42. Factors affecting Reportable Diseases in Ontario (1991-2016) 87 Typhoid Fever Figure 43. Ontario has had cases due to importation from parts of 59 the world where typhoid fever remains endemic, such as South Asia. Factors affecting Reportable Diseases in Ontario (1991-2016) 88 Verotoxin producing E. Factors affecting Reportable Diseases in Ontario (1991-2016) 89 2000 fi the increase in reported cases was attributed to a large waterborne outbreak in Walkerton, Ontario linked to the bacterial contamination of municipal water. Factors affecting Reportable Diseases in Ontario (1991-2016) 90 West Nile Virus Illness Figure 45. The suspect case definition includes clinical symptoms without requiring laboratory 4 confirmation. Factors affecting Reportable Diseases in Ontario (1991-2016) 91 2002 18 fi the first confirmed human cases in Ontario were detected. Factors affecting Reportable Diseases in Ontario (1991-2016) 92 Yesiniosis Figure 46. Factors affecting Reportable Diseases in Ontario (1991-2016) 93 Conclusion this report contributes to the interpretation of provincial infectious diseases surveillance data, serving as a knowledge product for the dissemination of information on reportable diseases in Ontario. Ongoing documentation of major changes to reportable disease status, case definitions, and other factors or events, such as outbreaks and changes to laboratory testing, which impact reportable disease trends in Ontario is needed for understanding and interpreting changes in trends. The historical changes and interpretation of trends obtained through this product will allow for a more meaningful comparison of reportable disease trends over time. Mandatory health programs and services: reportable disease information system: guidelines and procedures. Available from: Factors affecting Reportable Diseases in Ontario (1991-2016) 95. A new regulatory framework for federal food inspection: overview of proposed regulations [Internet]. The effects of changes in cervical cancer screening guidelines on chlamydia testing. High incidence of invasive group A Streptococcus disease caused by strains of uncommon emm types in Thunder Bay, Ontario, Canada. The 2008 Canadian Listeriosis outbreak: a result of knowledge ignored McMaster University Medical Journal. Public health notice update outbreak of Listeria infections linked to packaged salad products produced at the Dole processing facility in Springfield, Ohio [Internet]. Predicting the speed of tick invasion: an empirical model of range expansion for the Lyme disease vector Ixodes scapularis in Canada. Factors affecting Reportable Diseases in Ontario (1991-2016) 99 2012;49(2):457-64. Climate change and the potential for range expansion of the Lyme disease vector Ixodes scapularis in Canada. Population-based passive tick surveillance and detection of expanding foci of blacklegged ticks Ixodes scapularis and the Lyme disease agent Borrelia burgdorferi in Ontario, Canada. Spatiotemporal dynamics and demographic profiles of imported Plasmodium falciparum and Plasmodium vivax infections in Ontario, Canada (1990-2009):e76208. Coxiella burnetti (Q fever) abortion storms in goat herds after attendance at an annual fair. Seroprevalence of Coxiella burnetii in selected populations of domestic ruminants in Newfoundland. Towards tuberculosis elimination: an action framework for low-incidence countries. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted 2009, 2005, 2001, 1997, 1992, 1987 by Saunders, an imprint of Elsevier Inc. Lexicographer/Content Strategist: Sean Webb Content Development Specialist: Gabriela Benner Publishing Services Manager: Patricia Tannian Senior Project Manager: Carrie Stetz Design Direction: Paula Catalano Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 Preface this seventh edition of Dorland’s Dictionary of Medical Acronyms & Abbreviations (formerly Jablonski’s) is the second edition to be published since the original author, Stanley Jablonski, passed away. The book has been very well received over the years, and the author’s enthusiasm and love of medical vocabulary, even vexingly obscure abbreviations, are evident in its pages. The task of maintaining this volume now remains with the developer of Dorland’s dictionaries, who is well aware of the tradition of excellence associated with this dictionary. Although responsibility for updating the dictionary has changed, the content remains the familiar, convenient resource that has served users well for more than two decades. The print book retains its format of boldface abbreviations followed by run-in meanings, which enables it to encompass as many entries as larger, more cumbersome books while remaining an easy-to-handle size. The listings for organizations have been updated: new ones have been added; name changes have been incorporated; outdated names have been cross-referenced to new ones (or dropped, when thoroughly obsolete). The abbreviations and acronyms are presented alphabetically, and well over one thousand new additions and changes have been made. Also new to this edition is a section presenting acronyms and abbreviations that should not be used because they may be mistaken for other abbreviations or terms and carry with them a danger of being misconstrued. The new editor of Dorland’s Dictionary of Medical Acronyms & Abbreviations would like to express his appreciation for the work that has been handed down from the previous editors and Mr.
Flat Entrance along the Big Oak Flat Road departs several times daily from Yosemite with your registration; other lodging It’s also the starting point for ranger led (Highway 120 West) symptoms 7 days after implantation cheap 100 mcg cytotec with visa. We are here to medicine zebra buy cytotec in united states online help Join a photography expert from the Ansel the Restoration of the Mariposa Grove of to symptoms shingles cheap cytotec 100 mcg with visa change due to treatment 20 initiative buy cytotec 200 mcg cheap trafc and weather you enjoy Yosemite outdoor sports safely, Adams Gallery and learn how to best Giant Sequoias Project is now underway! Learn more and sign restoration project will improve the habitat Half Dome Village 8am and 10:30am We ofer professional guides for cross up at the Ansel Adams Gallery. Trails will be Majestic Hotel 8:15am and 10:45am hiking, and rock climbing (depending on improved providing universal access along Yosemite Valley Lodge 8:30am and 11am weather). Where to Go and What to Do in Yosemite National Park 11 Experience Your AmericaExperience Your America Yosemite National Park Discover Yosemite Stanislaus National Forest Let your curiosity guide you to new places Entrance Fees the Tioga and Glacier Point close to vehicle use after Non-commercial car, pickup the frst signifcant snowfall. Big Oak Interagency Annual Pass $80 Flat Yosemite Valid for 1 year at all federal recreation sites. Entrance Creek Tenaya Porcupine Lake Flat Interagency Senior Pass $80 120 (Lifetime) For U. Meadow Tuolumne Grove Tamarack Valley Interagency Annual Senior Pass $20 4 Flat Visitor (Annual) For U. Grove Valley Trailhead Glacier 2 Interagency Access Pass (Free) Point (Lifetime) For permanently disabled U. View El Portal Interagency Military Pass (Free) To l Glacier Point Road closed to vehicles (Annual) For active duty U. National 140 Yosemite Ski and Forest Yosemite Snowboard Interagency 4th Grade Pass (Free) West Area (Annual) For fourth graders and their families. Reservations Campground Reservations Ranger Station 877/444-6777 3 Food Service & Lodging Highway 120 West Yosemite Chamber of Commerce For a complete list of accessible services, recreational opportunities, and exhibits, pick up an updated Yosemite Accessibility Guide which is 800/449-9120 or 209/962-0429 available at park entrance stations, visitor centers, and online at Tuolumne County Visitors Bureau 800/446-1333 Accessible parking spaces are available just west of the Yosemite Valley Visitor Center. Refer to the Accessibility Guide, or contact an Highway 132/49 Accessibility Coordinator for more information. Other roads are generally 800/446-5353 or 209/724-8104 plowed and maintained, but can close or present delays during storms. Motorists are advised to always carry chains and check weather and road conditions To check road conditions, call 209/372-0200 for roads inside the park and 800/427-7623 Mariposa County Visitor Center or visit It is open year round and can be reached via Highway 41 from Fresno, Highway 140 from Merced, Highway 120 West from Manteca, and via the Tioga Road (Highway 120 East) from Lee Vining in summer. The Valley is known for massive clif faces like El Capitan and Half Dome, its plunging waterfalls including the tallest in North America, and its attractive meadows. While Yosemite Falls will be dry until rain and snow recharge it, a moderate hike will take you to Vernal and Nevada Falls. Yosemite’s meadows are great places to see wildlife and to photograph fall and winter scenery. Admire El Capitan, the massive granite monolith that stands 3,593 feet from base to summit. Whether you explore the Valley by foot, car or with a tour, the scenery will leave you in awe and eager to see what’s around the next corner. Photo by Christine Loberg Glacier Point Glacier Point, an overlook with a commanding view of Yosemite Valley, 2 Half Dome, and Yosemite’s high country, is located 30 miles (1 hour) from Yosemite Valley. The road stays open as weather permits, however, overnight parking along it ends October 15. Glacier Point Road closes beyond the Yosemite Ski and Snowboard Area after the frst signifcant snow fall. When the road is snowcovered and conditions permit, a system of cross-country ski tracks are maintained on it. From Yosemite Valley, take the Wawona Road (Highway 41), then turn left onto Glacier Point Road. At Glacier Point, when the road is open, a short, paved, and wheelchair-accessible trail takes you to an exhilarating view looking down 3,214 feet into Yosemite Valley. The Mariposa Grove of Giant Sequoias is currently closed for restoration, see page 1 for more details. The nearby Pioneer Yosemite History Center in Wawona is a collection of historic buildings associated with people and events that shaped the national park idea in Yosemite. Crane Flat Area Crane Flat is located 16 miles from Yosemite Valley at the junction of the Big 4 Oak Flat and Tioga Roads. A number of hikes through pleasant meadows are available—when snow covers the ground these turn into delightful ski and snowshoe tracks. To see giant sequoias, park at the Tuolumne Grove parking area located on the Tioga Road, and walk one steep mile down to the Tuolumne Grove of Giant Snow at Wawona’s covered bridge. Or, park at Merced Grove trailhead and walk two steep miles down to this small grove. These groves north of Yosemite Valley are smaller than the more-famous Mariposa Grove, but are quieter and of limits to vehicles. Tioga Road and Tuolumne Meadows the Tioga Road ofers a 39-mile scenic drive past forests, meadows, lakes, and 5 granite domes. The road closes after the frst big snowfall, and overnight parking ends on October 15. The Wild and Scenic Tuolumne River winds through broad sub-alpine meadows surrounded by granite domes and peaks. It is the jumping of place for countless hikes, whether you venture out for a day or a week. Photo by Wendy Malone Meadows is often reached by skiers via the Snow Creek Trail from the Mirror Lake trailhead, a short distance east of Yosemite Valley. Hetch Hetchy Hetch Hetchy Reservoir, a source of drinking water and hydroelectric power 6 for the City of San Francisco, is home to spectacular scenery and the starting point for many wilderness trails. The Hetch Hetchy Reservoir is located 40 miles (1fi hour) from Yosemite Valley via the Big Oak Flat Road (Highway 120W) and the Evergreen Road. Selfregistration permits for the Hetch Hetchy trailheads only are available at the kiosk. Anne’s and John’s prints share a common a fgurative tightrope between these old the Yosemite Valley Visitor Center Open daily from 9am to 5pm, may close beauty and luminosity. Exploring Light will be on display at the recognized as being signifcant to society. They are Looking West will honor the Ansel Adams Gallery between November located west of the main post ofce, near the Ansel Adams Gallery 12th, 2017 and January 7th 2018 and will determination of spirit of Ansel Adams shuttle stops #5 and #9. The facility ofers December 6 February 6 feature original gelatin silver photographs within his unique place in history by information, maps, and books. Explore Open 9am-5pm made by these two superb artists – displaying a variety of hand made the exhibits and learn how Yosemite’s Will close at 3 pm Dec 24 including new imagery hanging for the photographs from his lifetime. These landscape formed and how people Closed Dec 25 frst time on our wall, as well as classic and images will showcase a wide range of interact with it. The last Anne Larsen and John Sexton Adams will open at the Ansel Adams Gallery flm is at 4:30pm. Ken Burns’ Yosemite: A Exploring Light Ansel Adams is a distinct paradigm of the in Yosemite Village on January 8th, 2018 Gathering of Spirit plays on the hour and and run through February 24th, 2018. American West from his wild adventures the Spirit of Yosemite plays on the halfthis will be a unique two-person exhibition to his modern methods and embrace of hour, in the Theater behind the Yosemite by noted fine art photographers Anne technology, along with his romanticizing Yosemite Art Center Valley Visitor Center. The museum is open have a passion for the sheer beauty of the twentieth century, a time that saw two daily from 9am to 5pm, may close for lunch. As a Interprets the cultural history of only stunning images of the natural curious witness, it is no less important Yosemite’s Miwok and Paiute people environment, but will also incorporate that Ansel found his artist’s voice by from 1850 to the present. For each of the two interpreting this old landscape through a Cultural Museum is open from 9am to photographers the use of light as it graces recent advancement in technology — the 5pm, may close for lunch. Explore winter ecology and learn key survival skills during a day in a sequoia 5:30pm Tom Bopp Performing at the Piano grove. Conditions permitting, meet at Lodge lobby as he performs songs and Yosemite Ski and Snowboard Area Ranger offce A-frame for naturalist tour of winter landscape.
Retinopathy and plications Trial/Epidemiology of Diabetes Interven(54 mg/dL) should be reported in clinical trials: nephropathy in patientswithtype 1 diabetesfour tions and Complications and Pittsburgh Epidemiology a joint position statement of the American Diabeyears after a trial of intensive therapy symptoms food poisoning cheap 100 mcg cytotec free shipping. Hypodiabetic microvascular complications in Japanese Association between 7 years of intensive treatglycemia anddiabetes:a report of aworkgroupof patients with non-insulin-dependent diabetes ment of type 1 diabetes and long-term mortality medications that cause hyponatremia purchase cytotec online pills. Effect of intensive blood-glucose control of Cardiology Foundation; American Heart Assodementia in older patients with type 2 diabetes with metformin on complications in overweight ciation symptoms zoloft overdose discount cytotec 100 mcg free shipping. Diational treatment and risk of complications in the American Heart Association symptoms knee sprain buy cytotec 100 mcg cheap. Severe hypoglycemia and cular and microvascular complications of type 2 Engl J Med 2015;372:2197–2206 risks of vascular events and death. Glucose control and vascular correction appears in Diabetologia 2009;52: talityofpatientswithdiabetesreportingsevere complications in veterans with type 2 diabetes. Potential overtreatment of diabeof transplantation of human islets in type 1 diaof hyperglycaemia on microvascular outcomes in tes mellitus in older adults with tight glycemic betes complicated by severe hypoglycemia. Diverse causes of hypoglycemiaEpidemiologyofDiabetesInterventionsandComposition statement of the American Diabetes Assoassociated autonomic failure in diabetes. Inciation and the European Association for the Study J Med 2004;350:2272–2279 tensive diabetes treatment and cardiovascular of Diabetes. Diabetes Care 2009;32:1335–1343 Diabetes Care Volume 41, Supplement 1, January 2018 S65 American Diabetes Association 7. There is strong and consistent evidence that obesity management can delay the progression from prediabetes to type 2 diabetes (1,2) and may be beneficialin the treatment oftype2 diabetes (3–8). In overweight and obese patients with type 2 diabetes, modest and sustained weight loss has been shown to improve glycemic control and to reduce the need for glucose-lowering medications (3–5). Small studies have demonstrated that in obese patients with type 2 diabetes more extreme dietary energy restriction with verylow-calorie diets can reduce A1C to,6. Weight loss–induced improvements in glycemia are most likely to occur early in the natural history of type 2 diabetes when obesity-associated insulin resistance has caused reversible b-cell dysfunction but insulin secretory capacity remains relatively preserved (5,8,10,11). The goal of this section is to provide evidencebased recommendations for dietary, pharmacologic, and surgical interventions for obesity management as treatments for hyperglycemia in type 2 diabetes. S66 Obesity Management for the Treatment of Type 2 Diabetes Diabetes Care Volume 41, Supplement 1, January 2018 Table 7. Participants who had modloss, such programs must incorpoclude diet, physical activity, behavioral erately or poorly controlled diabetes (A1C rate long-term comprehensive therapy, pharmacologic therapy, and met6. The latter two well-controlled diabetes (A1C less than strategies may be prescribed for carefully 6. Greater c Diet,physical activity, and behaviorenergy deficit or provide approximately weight loss produces even greater benealtherapydesigned toachieve. Use of meal replacethose that provide the same caloric cardiovascular events in overweight or ment plans prescribed by trained practirestriction but differ in protein, carboobese adults with type 2 diabetes (15), it tioners, with close patient monitoring, hydrate, and fat content are equally did show the feasibility of achieving and can be beneficial. A maintaining long-term weight loss in palifestyle intervention group of the Look c For patients who achieve shorttients with type 2 diabetes. Such programs should sive lifestyle intervention participants patient’s health status and preferences. Partictions should include $16 sessions in of body weight (weekly or more freipants randomly assigned to the intensive 6 months and focus on diet, physical acquently), continued consumption lifestyle group achieved equivalent risk tivity, andbehavioral strategiestoachieve of a reduced-calorie diet, and parfactor control but required fewer glucose-, an;500–750 kcal/day energy deficit. Inticipation in high levels of physical blood pressure–, and lipid-lowering medterventionsshould beprovided bytrained activity (200–300 min/week). A ications than those randomly assigned to interventionists in either individual or c To achieve weight loss of. Agents associated with weight loss force lifestyle changes including physical trained interventionist and focus on oninclude metformin, a-glucosidase inhibiactivity. Providers should be knowledgegoing monitoring of body weight (weekly tors, sodium–glucose cotransporter 2 inable about the product label and should or more frequently), continued consumphibitors, glucagon-like peptide 1 agonists, balance the potential benefits of successtion of a reduced-calorie diet, and particandamylinmimetics. Dipeptidyl peptidase ful weight loss against the potential risks ipationinhighlevelsofphysicalactivity 4 inhibitors appear to be weight neutral. Some comUnlike these agents, insulin secretagogues, medications are contraindicated in women mercial and proprietary weight loss prothiazolidinediones, and insulin have often who are or may become pregnant. Women grams have shown promising weight loss been associated with weight gain (see in their reproductive years must be cautioned results (25). Assessing Efficacy and Safety in medical care settings withclose medical A recent meta-analysis of 227 randomEfficacyandsafetyshouldbeassessedatleast monitoring, short-term (3-month) interized controlled trials of antihyperglycemic monthly for the first 3 months of treatment. Whenever possithe rationale for weight loss medications tine monitoring of micronutrient ble, medications should be chosen to is to help patients to more consistently S68 Obesity Management for the Treatment of Type 2 Diabetes Diabetes Care Volume 41, Supplement 1, January 2018 care. C postoperative follow up ranging from bolic surgery in such patients will require c People presenting for metabolic 1 to 5 years have documented sustained larger and longer studies (72). Available data suggest an erosion of studies suggest that metabolic surgery B Surgery should be postponed in diabetes remission over time (51): 35– may be cost-effective or even cost-saving patients with histories of alcohol or 50% or more of patients who initially for patients with type 2 diabetes, but the substance abuse, significant depresachieve remission of diabetes eventually results are largely dependent on assumpsion, suicidal ideation, or other mental experience recurrence. However, the metions about the long-term effectiveness health conditions until these condidian disease-free period among such inand safety of the procedures (73,74). With gery should be evaluated to assess Adverse Effects or without diabetes relapse, the majority Metabolic surgery is costly and has associthe need for ongoing mental health of patients who undergo surgery mainated risks. Longer-term concerns include services to help them adjust to tain substantial improvement of glycemic medical and psychosocial changes dumping syndrome (nausea,colic,diarrhea), controlfrom baseline for at least 5 (54,55) after surgery. Candidates for metabolic obese patients with type 2 diabetes comthe safety of metabolic surgery has imsurgery with histories of alcohol or subpared with various lifestyle/medical interproved significantly over the past two destance abuse, significant depression, suiventions (35). Improvements in microand cades, with continued refinement of cidal ideation, or other mental health macrovascular complications of diabetes, minimally invasive approaches (laparoconditions should therefore first be ascardiovascular disease, and cancer have scopic surgery), enhanced training and sessed by a mental health professional been observed only in nonrandomized credentialing, and involvement of multiwith expertise in obesity management prior observational studies (37–46). Individustudies attempting to match surgical metabolic operations are typically 0. Major complications rates chiatric symptoms do not interfere with several organizations and government are 2–6%, with minor complications in weight loss and lifestyle changes. Targetingweightlossinterventions 2015;373:11–22 Reduction in the incidence of type 2 diabetes to reduce cardiovascular complications of type 2 33. N Engl J diabetes: a machine learning-based post-hoc ciation of pharmacological treatments for obesity Med 2002;346:393–403 analysis of heterogeneous treatment effects in with weight lossand adverse events: a systematic 3. Lifestyle weight-loss intervention domized placebo-controlled clinical trial of lorca1990;39:905–912 outcomes in overweight and obese adults with serin for weight loss in type 2 diabetes mellitus: 4. The evidence for the effectiveness of son of weight-loss diets with different composiabolic surgery in the treatment algorithm for medical nutrition therapy in diabetes managetions of fat, protein, and carbohydrates. Effect of duodenalabetes: normalisation of beta cell function in ascarbohydrate on fat mass, lean mass, visceral adjejunal exclusion in a non-obese animal model sociation with decreased pancreas and liver ipose tissue, and hepatic fat: results from the of type 2 diabetes: a new perspective for an old triacylglycerol. Partial meal reAssociationof bariatric surgery withlong-termrediabetes: an underutilized therapyfi Clinicaloutcomesofmetabolicsurgery:efficacy cacy of commercial weight-loss programs: an upet al. Effects of of glycemic control, weight loss, and remission of dated systematic review. The evolution of verytients in Sweden (Swedish Obese Subjects Study): American College of Cardiology/American Heart low-calorie diets: an update and meta-analysis. Lancet Association Task Force on Practice Guidelines; Obesity (Silver Spring) 2006;14:1283–1293 Oncol 2009;10:653–662 Obesity Society. Appropriate body-mass index for Asian Baseline body mass index and the efficacy of hysociation between bariatric surgery and longpopulations and its implications for policy and inpoglycemic treatment in type 2 diabetes: a metaterm survival. The DiSpring) 2014;22:5–13 2010;376:595–605 abetes Surgery Summit consensus conference: 17. Ann Surg 2010;251:399–405 S72 Obesity Management for the Treatment of Type 2 Diabetes Diabetes Care Volume 41, Supplement 1, January 2018 48. Care 2016;39:941–948 Lancet 2011;378:108–110 Roux-en-Y gastric bypass surgery or lifestyle with 73. Obes Surg 2012;22: type 2 diabetes: feasibility and 1-year results rierstoappropriateuseofmetabolic/bariatricsur677–684 of a randomized clinical trial. Diabetes Care 2016;39:954–963 bility of addition of Roux-en-Y gastric bypass to 62. Surg Clin North Am trolled type 2 diabetes in mild to moderate obeassessment of bariatric surgery. Bariatric surogists; Obesity Society;AmericanSociety for Metmultisite study of long-term remission and regery for obesity and metabolic conditions in abolic & Bariatric Surgery. Obes Surg 2013;23:93–102 Use and outcomesof laparoscopic sleevegastrecSurgery medical guidelines for clinical practice 54.
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