X. Jarock. Claremont McKenna College.

Clinicians must also consider their own experience purchase ibuprofen 400 mg line, expertise generic ibuprofen 600mg on-line, and preferences in the decision-making process trusted ibuprofen 400 mg. Nonetheless, books can still retain value in providing information about more basic concepts, in introducing specific skills with a presumed longer shelf life, and in providing a his- toric context for a broad area of study. In addition, they can provide a more detailed account of theoretical underpinnings and clinical procedures than is often possible in other types of publications. All of these potential advantages of textbook descrip- tions of child language interventions can be found in the chapters represented in this volume. Furthermore, despite their strong negative views on traditional textbooks, Sackett and his colleagues acknowledged that some textbooks are organized with an eye toward clinical use and that much of the information they contain will actually be current because newer, contradictory information has not yet appeared. To min- imize their potential weaknesses, however, Sackett and colleagues recommended that textbooks be revised frequently, be heavily referenced with regard to clinical recommendations so that outdated information can be more readily spotted, and be constructed with an eye to explicit principles of evidence. Although a 10-year sepa- ration between the first and second editions of this volume means we may not have fully lived up to Sackett and his colleagues’ first piece of advice, we have made our best efforts to adhere to the remainder. The present volume has been constructed as much as possible to approach the ideals mapped out by Sackett and colleagues (2000). For example, numerous refer- ences are provided to establish the time frame of particular ideas and pieces of infor- mation. Through the use of the standard template described previously in this chap- ter, authors were encouraged to discuss the quality of the evidence they provided Excerpted from Treatment of Language Disorders in Children, Second Edition by Rebecca J. Nonetheless, all readers are cautioned that this volume is more likely to remain a useful resource for a reasonable period of time if viewed as a preliminary, rather than exhaustive, source of information and if its chapters are recognized as narrative reviews written by advocates of the approaches they describe rather than as systematic reviews, meta-analyses, or practice guidelines. Since the first edition of this book, not only has evidence-based practice be- come a term that is familiar to almost all clinicians, its wholehearted adoption by the American Speech-Language-Hearing Association has led to the development of many informational resources designed to ease access to sources of research evidence. Although an exhaustive list of such resources is beyond the scope of this chapter and might be overwhelming to the point of diminishing value in any case, Table 1. Available information on client/patient/caregiver perspectives and clinical expertise/expert opinion are also provided for each disorder category. First, consider the information in the Target Populations and the Empirical Basis sections of each chapter as an initial, possibly biased, and al- most certainly nonexhaustive survey of the available research literature. Second, from this skeptical perspective, determine whether evidence presented in these same sections is applicable to a specific child you are considering as a potential candidate for the treatment. If it is not, is there any theoretical reason that would make the intervention more or less effective with the target child? Third, based on the information in the Practical Requirements, Key Components, and Application to an Individual Child sections and from an examination of the video clips, is the approach feasible for the target child under existing circumstances? Do you have the resources to implement the approach at an intensity level close enough to that observed in studies cited to make a successful outcome likely? Fourth, identify at least one of the articles used by the authors as strong support for the methods they describe and critically examine the original research report. Does the evidence pre- sented in the research report support a decision to attempt the technique with the target child in the manner and to the degree anticipated based on the conclusions of the chapter authors? Fifth, do an additional computer-based search for at least one article that is more recent than the literature cited in the article and potentially relevant for the target child. Are the results of this study consistent with a decision to use the approach or to try some alternative? At a minimum, the clinician should address each of the following questions as part of this critical evaluation: 1) Does the research report include chil- dren like the one being considered for treatment? This could include multiple baselines for treated and untreated goals in single-subject experiments, or the use of a control group in a group design. For students who are interested in learning about interventions for children with language disorders, we have one overriding recommendation. We urge them to adopt the perspective described previously for practicing clinicians, anticipating that al- though they may not have their own clients yet, they soon will have. We recognize that learning in the abstract about treatment theory, evidence, and structure is a daunting and less rewarding task than framing such work in terms of an individual; therefore, we recommend that as much as possible they consider the content they are reading in light of case descriptions provided by their instructors or included in each chapter. It may even be helpful to view the intervention’s video content or read the Application to an Individual Child section as a first step before tackling an intervention chapter from Excerpted from Treatment of Language Disorders in Children, Second Edition by Rebecca J. In addition, the next section on Learning Activities has been created to suggest exercises that may promote critical thinking and clinical problem solving. Choose two interventions that interest you in general or that might inter- est you because both might be considered for use with a given child. Using information from their respective chapters, compare these interventions in terms of factors such as 1) the strength of evidence supporting their efficacy and effectiveness, 2) their practical demands, and 3) how easy they might be to learn. How would you weight the importance of each of these factors in helping you make a decision about using the interventions? Are there additional factors that you would need to consider before making a decision to use the intervention? For an individual treatment chapter, look at one or two studies listed at each level in the chapter’s levels of evidence tables. If you disagree on more than one or two, what strategies might you use to get additional information about how well this intervention is supported by external evidence? If you found this task difficult, identify one step that you might take to improve your understanding of such systems. Look for an individual treatment chapter that seems to have fewer studies that provide higher levels of support than other chapters in the book. If you were to decide to use that intervention, what repercussions does this lower level of research support have for how you would use it? Also, how would that lower level of evidence affect what you would say to families or other colleagues about that decision? Look at the Theoretical Basis sections of several or even all of the treatment chap- ters. Are there other theories that are mentioned only in relation to one or two interventions? What treatment-related processes do the different theories attempt to account for; for example, are the theories addressing typical development, learning, the nature of the disorder or specific symptom, or the use of strengths to compensate for challenges? Look at the video clip associated with it and then reread the chapter’s section on the intervention’s key elements. Also, were there elements that were not identified in the chapter that you saw as distinctive or important features of the therapeutic interaction in the video? Optimal intervention intensity in speech-language pathology: Discoveries, challenges, and unchartered territories. Evidence-based practice: An examination of its ramifications for the practice of speech-language pathology. Ten questions about terminology for children with unexplained lan- guage problems. Statistical, practical, clinical, and personal significance: Definitions and applications in speech-language pathology. Evidence-based systematic review: Effects of intensity of treatment and constraint-induced language therapy for individuals with stroke induced aphasia. Bridging the research-to-practice gap in autism intervention: An application of diffusion of innovation theory. Understanding and narrowing the gap between treatment research and clinical practice with language impaired children. Twenty-year follow-up of children with and without speech-language impairments: Family, educational, occupational and qual- ity of life outcomes. Designing caregiver-implemented shared reading interventions to overcome implementation barriers. To use or not to use: Factors that influence the selection of new treatment approaches. Treating children with speech and language impairments: Six hours of therapy is not enough. A clinician’s introduction to systematic reviews in communication disorders: The course review paper with muscle. The effects of visual stimuli on the spoken narrative performance of school- age African American children. Dynamic assessment of narrative ability in English accurately identifies language impairment in English language learners. Optimal intervention intensity for emergent literacy: What we know and need to learn. Assessment of language and literacy disorders: A process of hypothesis test- ing for individual differences.

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Before starting initial controller treatment • Record evidence for the diagnosis of asthma buy ibuprofen 400 mg online, if possible • Document symptom control and risk factors • Assess lung function order 600mg ibuprofen overnight delivery, when possible • Train the patient to use the inhaler correctly buy ibuprofen 600mg on-line, and check their technique • Schedule a follow-up visit After starting initial controller treatment • Review response after 2–3 months, or according to clinical urgency • See Box 7 for ongoing treatment and other key management issues • Consider step down when asthma has been well-controlled for 3 months 13 Box 7. Other options: Add-on tiotropium by soft-mist inhaler for adults (≥18 years) with a history of exacerbations. Patients should preferably be seen 1–3 months after starting treatment and every 3–12 months after that, except in pregnancy when they should be reviewed every 4–6 weeks. The frequency of review depends on the patient’s initial level of control, their response to previous treatment, and their ability and willingness to engage in self-management with an action plan. Stepping up asthma treatment Asthma is a variable condition, and periodic adjustment of controller treatment by the clinician and/or patient may be needed. Stepping down treatment when asthma is well-controlled Consider stepping down treatment once good asthma control has been achieved and maintained for 3 months, to find the lowest treatment that controls both symptoms and exacerbations, and minimizes side-effects. To ensure effective inhaler use: • Choose the most appropriate device for the patient before prescribing: consider medication, physical problems e. Check and improve adherence with asthma medications Around 50% of adults and children do not take controller medications as prescribed. Some examples with consistent high quality evidence are: • Smoking cessation advice: at every visit, strongly encourage smokers to quit. Advise parents and carers to exclude smoking in rooms/cars used by children with asthma • Physical activity: encourage people with asthma to engage in regular physical activity because of its general health benefits. Although allergens may contribute to asthma symptoms in sensitized patients, allergen avoidance is not recommended as a general strategy for asthma. These strategies are often complex and expensive, and there are no validated methods for identifying those who are likely to benefit. For baby and mother, the advantages of actively treating asthma markedly outweigh any potential risks of usual controller and reliever medications. For some patients, treatment with intranasal corticosteroids improves asthma control. Obesity: to avoid over- or under-treatment, it is important to document the diagnosis of asthma in the obese. Weight reduction should be included in the treatment plan for obese patients with asthma; even 5–10% weight loss can improve asthma control. The elderly: comorbidities and their treatment should be considered and may complicate asthma management. Factors such as arthritis, eyesight, inspiratory flow, and complexity of treatment regimens should be considered when choosing medications and inhaler devices. Symptomatic reflux should be treated for its general health benefits, but there is no benefit from treating asymptomatic reflux in asthma. Anxiety and depression: these are commonly seen in people with asthma, and are associated with worse symptoms and quality of life. Patients should be assisted to distinguish between symptoms of anxiety and of asthma. Food allergy and anaphylaxis: food allergy is rarely a trigger for asthma symptoms. Good asthma control is essential; patients should also have an anaphylaxis plan and be trained in appropriate avoidance strategies and use of injectable epinephrine. Surgery: whenever possible, good asthma control should be achieved pre- operatively. Ensure that controller therapy is maintained throughout the peri- operative period. The management of worsening asthma and exacerbations should be considered as a continuum, from self-management by the patient with a written asthma action plan, through to management of more severe symptoms in primary care, the emergency department and in hospital. Identifying patients at risk of asthma-related death These patients should be identified, and flagged for more frequent review. Patients who deteriorate quickly should be advised to go to an acute care facility or see their doctor immediately. Oral corticosteroids (preferably morning dosing): • Adults - prednisolone 1mg/kg/day up to 50mg, usually for 5–7 days. Arrange immediate transfer to an acute care facility if there are signs of severe exacerbation, or to intensive care if the patient is drowsy, confused, or has a silent chest. Check response of symptoms and saturation frequently, and measure lung function after 1 hour. Titrate oxygen to maintain saturation of 93–95% in adults and adolescents (94–98% in children 6–12 years). In acute care facilities, intravenous magnesium sulfate may be considered if the patient is not responding to intensive initial treatment. Do not routinely perform chest X-ray or blood gases, or prescribe antibiotics, for asthma exacerbations. Decide about need for hospitalization based on clinical status, symptomatic and lung function, response to treatment, recent and past history of exacerbations, and ability to manage at home. For most patients, prescribe regular controller therapy (or increase current dose) to reduce the risk of further exacerbations. Continue increased controller doses for 2–4 weeks, and reduce reliever to as-needed. Consider referral for specialist advice for patients with an asthma hospitalization, or repeated emergency department presentations. All patients must be followed up regularly by a health care provider until symptoms and lung function return to normal. Take the opportunity to review: • The patient’s understanding of the cause of the exacerbation • Modifiable risk factors for exacerbations, e. Comprehensive post-discharge programs that include optimal controller management, inhaler technique, self-monitoring, written asthma action plan and regular review are cost-effective and are associated with significant improvement in asthma outcomes. Leukotriene modifiers Target one part of the inflammatory Few side-effects except (tablets) e. Used as an option for elevated liver function tests pranlukast, zafirlukast, controller therapy, particularly in children. Require inhalation and pharyngeal nedocromil sodium meticulous inhaler maintenance. Long-acting An add-on option at Step 4 or 5 bny soft- Side-effects are uncommon anticholinergic, tiotropium mist inhaler for adults (≥18 years) whose but include dry mouth. This report, provides an integrated approach to asthma that can be adapted for a wide range of health systems. The report has a user-friendly format with practical summary tables and flow-charts for use in clinical practice.

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The reduction of the global area under coca culti- year that the coca fields were productive before being ibuprofen 400 mg without a prescription, vation since 2007 has been driven by significant decreases for example cheap 400 mg ibuprofen amex, eradicated or abandoned (net productive in Colombia buy ibuprofen 400 mg cheap, which have been only partially offset by area). The area under cultivation at a specific cut-off increases in the Plurinational State of Bolivia and Peru date may be chosen for other reasons, for example, to over the same period. This longevity of the coca plant currently in place in the Plurinational State of Bolivia, should, in principle, make it easier to measure the area Colombia and Peru have developed different ways of under coca cultivation. In reality, the area under coca tackling the challenge of measuring the dynamics of cultivation is dynamic, changes all the time and it is dif- coca cultivation, depending on specific country factors, ficult to determine the exact amount of land under coca the availability of auxiliary information on eradication, cultivation at any specific point in time or within a given as well as practical and financial considerations. There are several reasons why coca cultivation is this approach helps to adjust the monitoring systems to dynamic: new plantation, abandonment of fields, reac- the specificities of each country, it also limits the com- tivation of previously abandoned fields, manual eradica- parability of the area under cultivation across countries. Total area under coca cultivation in 2010 is based on the 2009 figure for Bolivia and will be revised once the 2010 figure becomes available. For Colombia, the series without adjustment for small fields was used to keep comparability. Cultivation of coca from being primarily concerned with the area under bush decreased in all major growing regions of the coun- coca cultivation to getting a better understanding of try. The Pacific region remained the region with the how much cocaine is being produced. This is partly due largest coca cultivation, representing 42% (25,680 ha) to more appreciation of the fact that eradication, whether of the national total, followed by the Central (25% or carried out manually or by aerial spraying, does not 15,310 ha) and Meta-Guaviare regions (14% or 8,710 necessarily translate into a corresponding reduction of 1 ha). The impact of eradication carried out between date A and date B may or may not be seen by Table 22: Approaches to measure coca comparing the area under coca at these two points in cultivation (ha), 2010 time but it will certainly be noticeable in the coca yield Net cultivation Productive coca as farmers lose harvests or have to replant their fields. Total area under coca cultivation in 2010 is based on the 2009 figure for Bolivia and will be revised once the 2010 figure becomes coca cultivation is considered for the number of months available. An Peru, the area estimated from satellite imagery represents increasing proportion of coca was cultivated on small the average coca cultivation situation in the second half fields. This raised concerns because the type of satellite of the year, and it is used directly to estimate produc- imagery used to detect coca fields in Colombia works tion. Thus, a study using very high resolution imagery was conducted to determine the proportion of coca grown Efforts are being made in all three countries to improve on fields below the 0. Based on this the cocaine production estimates and the concepts of the net area and the productive area - detailed below - are an important part of that process. The lack of precise measure- adjustment for 68,000 57,000 -16% ments of laboratory efficiency in the different countries small fields increases the level of uncertainty, but does not affect the With adjustment trend, which shows a clear decline in global cocaine 73,000 62,000 -15% for small fields production since 2007. This adjustment allows for the inclusion of coca already reached efficiency levels comparable to Colom- cultivated fields that are smaller than the detectable 3 bia. Thus, in other parts of this Report, the upper end threshold, and thereby improves the accuracy of the coca of the global cocaine production range has been area estimate in Colombia. This, despite the uncertainty associated with the In 2010, the area under coca cultivation was estimated estimate, is considered to be a better approximation of at 57,000 ha without the adjustment for small fields. To facilitate a comparison with 2009, the 2009 figure was also corrected, from 68,000 ha without Cocaine production in Peru has been going up since to 73,000 ha with the adjustment for small fields. Coca leaf Peru yields in Colombia have been regularly studied and In Peru, in 2010, the area under coca cultivation updated since 2005, and part of the decline in Colom- amounted to 61,200 ha, a 2% increase (+1,300 ha) on bian cocaine production is due to declining yields. However, Peru, on the other hand, information on coca leaf yields the coca-growing regions showed diverging cultivation dates back to 2004, and for some of the smaller cultivat- trends. Upper Huallaga, the largest growing region in ing regions, which experienced significant increases in recent years, experienced a strong decline of almost the area under coca, no information on region-specific coca leaf yields is available. In Apurímac-Ene, lenges involved in estimating the yield of new or reacti- the second largest growing region until 2009, a signifi- vated coca fields as opposed to mature, well-maintained cant increase in the area under coca of more than 2,200 ones, as well as the effects of continued eradication pres- ha was registered, and with 19,700 ha, it became the sure. As noted above, there are indications that the level largest growing region in 2010. Colombia Some smaller growing regions such as Aguatiya and Inambari-Tambopata, which have experienced a signifi- Cocaine production in Colombia decreased to 350 mt cant increase in the area under coca in recent years, in 2010. The drop since 2005 is the result of a decrease remained relatively stable in 2010. Within this framework, about the comparability of the estimates between coun- several studies analysed coca leaf to cocaine conversion methods. There are also indications of structural amounted to almost 155,000 mt, an increase by 16%. Unlike in the Plurinational State of Bolivia and that it happened despite an overall decline in coca leaf Peru, where farmers sun-dry the coca leaves to increase production in Colombia over this period. What could lead farmers to stop 24% of the coca leaf produced in that year was sold as processing coca leaves themselves and sell them instead? The estimated amount of coca leaf produced on 12,000 ha in the Yungas of La Paz where coca cultivation is authorized under national law, was deducted. Range: Upper and lower bound of the 95% confidence interval of coca leaf yield estimate. In the case of Bolivia and Peru, the ranges are based on confidence intervals and the best estimate is the mid-point between the upper and lower bound of the range. In the case of Colombia, the range represents the two approaches taken to calculate the productive area, with the lower bound being closer to the estimation used in previous years. The methodology to calculate uncertainty ranges for production estimates is still under development and figures may be revised when more information becomes available. Total 1,020 1,034 1,024 865 * * * Due to the ongoing review of conversion factors, no point estimate of the level of cocaine production could be provided for 2009 and 2010. Because of the uncertainty about the level of total potential cocaine production and about the comparability of the estimates between countries, the 2009 and 2010 figures were estimated as ranges (842-1,111 mt and 786-1,054 mt, respectively). Due to the introduction of an adjustment factor for small fields, 2010 estimates are not directly comparable with previous years. Detailed information on the ongoing revision of conversion ratios and cocaine laboratory efficiency is available in the World Drug Report 2010 (p. Information on estimation methodologies and definitions can be found in the Methodology chapter of this Report. Another measure taken by traffickers was the introduc- 600,000 tion of a previously unknown process called re-oxidation of cocaine base. This process is apparently an additional 500,000 step used to homogenize and improve the quality of cocaine base of different quality received from different 400,000 sources and geographic areas by using potassium per- manganate. Coca leaf sold as leaf by farmers (mt) Plurinational State of Bolivia It can be assumed that, following the trend in cultiva- bia, quality differences in the coca paste and cocaine tion, cocaine production in Bolivia increased between base provided by coca farmers reportedly became a prob- 2005 and 2009. There are indications A strategy employed by traffickers to obtain cocaine base that since about 2007, clandestine laboratories in Bolivia of better or more homogeneous quality could be to try have benefited from a transfer of know-how from to execute more control over the cocaine alkaloid extrac- Colombia. Skilled ‘cooks’ with better know-how, are much more efficient in extracting cocaine from coca equipment and precursor chemicals may be in a better leaves. More research is needed to better understand the position than farmers to produce cocaine base with the current efficiency of clandestine laboratories in Bolivia. It is not yet known how the purchasing of coca leaf from farmers is organized and Clandestine processing installations who the actors are. The illicit extraction of cocaine alkaloids from coca leaves What could have caused the apparent quality differences takes place exclusively in the three countries cultivating in the cocaine base produced by farmers? In 2009, the destruction of 8,691 pressure, the per-hectare yields of coca fields went down installations involved in the production of coca paste or in many growing regions of Colombia and there is a base was reported. This may make the destruction of maceration pits, a typical feature of coca paste production in the Plurinational State of Bolivia assembly of amounts of coca leaves large enough for and Peru. As coca leaf is not sun-dried in Colombia, storing the leaves until a sufficient amount is accumulated is not an option, as fresh coca leaves deteriorate rapidly in quality. An additional reason might be that, in 2009, it was more risky for farmers to engage in coca-processing in areas where the Government has increased its presence compared to 2005. Selling coca leaf rather than keeping processing chemicals and equipment on the farm may be part of a risk-aversion strategy employed by farmers. First, coca leaf is processed or traded in Colombia as fresh coca leaf, immediately after the harvest, whereas in Peru and the Plurinational State of Bolivia, farmers dry the fresh coca leaf before selling, by spreading the leaves on the ground and exposing them to air. The result is coca leaf with a much reduced moisture, which makes transport easier and allows storage of the leaves. The second reason is that the moisture content of both fresh and sun-dried coca leaf varies considerably, depending on the biological properties of the leaf as well as environmental factors such as the humidity of the air. A fresh coca leaf harvested in the early morning, for example, will have a different moisture content than leaves from the same bush plucked at noon. Coca leaves sun-dried after a heavy rainfall at a low altitude will have a different moisture content than leaves sun-dried in the dry season at a high altitude. While differences may not matter much to farmers selling coca leaves, it matters from a scientific point of view, when comparing coca leaf production in different countries and estimating how much cocaine can potentially be extracted from the leaves. In other words, scientists are interested in how much dry plant matter is in the leaves, and which proportion of that dry matter consists of cocaine alkaloids.

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Several case series and a Type 1 Diabetes ser photocoagulation is still commonly controlled prospective study suggest that Because retinopathy is estimated to take used to manage complications of diabetic pregnancy in patients with type 1 diabetes at least 5 years to develop after the onset retinopathythat involveretinalneovascu- may aggravate retinopathy and threaten of hyperglycemia ibuprofen 600mg free shipping, patients with type 1 di- larization and its complications generic ibuprofen 600mg free shipping. Symptoms vary agents provide a more effective treat- vent or delay the development of according to the class of sensory fibers ment regimen for central-involved dia- neuropathy in patients with type 1 involved buy cheap ibuprofen 400mg on-line. The most common early symp- betic macular edema than monotherapy diabetes A andtoslowthepro- toms are induced by the involvement of or even combination therapy with laser gression of neuropathy in patients small fibers and include pain and dyses- (69–71). B thesias (unpleasant sensations of burning In both trials, laser photocoagula- c Assess and treat patients to reduce and tingling). The following sion and has replaced the need for recommended as initial pharmaco- clinical tests may be used to assess small- laser photocoagulation in the vast ma- logic treatments for neuropathic and large-fiber function and protective jority of patients with diabetic macular pain in diabetes. Most pa- tients require near-monthly adminis- The diabetic neuropathies are a hetero- 1. Large-fiber function: vibration per- 12 months of treatment with fewer in- nition and appropriate management of ception, 10-g monofilament, and an- jections needed in subsequent years neuropathy in the patient with diabetes kle reflexes to maintain remission from central- is important. Diabetic neuropathy is a diagnosis of These tests not only screen for the pres- potentially viable alternative treat- exclusion. Numerous treatment options exist is rarely needed, except in situations pharmacologic agents are currently for symptomatic diabetic neuropathy. Specific treatment for the underlying betes and at least annually nerve damage, other than improved gly- Diabetic Autonomic Neuropathy thereafter. Major clinical manifestations of di- of either temperature or pinprick modestly slow their progression in abetic autonomic neuropathy include sensation (small-fiber function) type 2 diabetes (16) but does not hypoglycemia unawareness, resting and vibration sensation using a reverse neuronal loss. Therapeutic strat- tachycardia, orthostatic hypotension, 128-Hz tuning fork (for large-fiber egies (pharmacologic and nonpharma- gastroparesis, constipation, diarrhea, function). S94 Microvascular Complications and Foot Care Diabetes Care Volume 40, Supplement 1, January 2017 Cardiac Autonomic Neuropathy Treatment 50% improvement in pain (88,90,92–95). Although the evidence for the lower starting doses and more gradual resting tachycardia (. In a post hoc analysis, partici- ized trials, although some of these had Gastrointestinal Neuropathies pants, particularly men, in the Bypass An- high drop-out rates (88,90,95,97). In longer-term tract with manifestations including with insulin sensitizers had a lower inci- studies, a small increase in A1C was esophageal dysmotility, gastroparesis, dence of distal symmetric polyneurop- reported in people with diabetes treat- constipation, diarrhea, and fecal inconti- athy over 4 years than those treated ed with duloxetine compared with pla- nence. Adverse events may be more in individuals with erratic glycemic control Neuropathic Pain severe in older people, but may be at- or with upper gastrointestinal symptoms Neuropathic pain can be severe and can tenuated with lower doses and slower without another identified cause. No compelling evidence analgesic that exerts its analgesic effects esophagogastroduodenoscopy or a bar- exists in support of glycemic control or through both m-opioid receptor ago- ium study of the stomach) is needed lifestyle management as therapies for nism and noradrenaline reuptake inhibi- before considering a diagnosis of or spe- neuropathic pain in diabetes or predia- tion. Health Canada, and the European Med- pants titrated to an optimal dose of 13 The use of Coctanoicacidbreathtest icines Agency for the treatment of neu- tapentadol were randomly assigned to is emerging as a viable alternative. The opioid continue that dose or switch to placebo Genitourinary Disturbances tapentadol has regulatory approval in (101,102). Comparative tapentadol and therefore their results including sexual dysfunction and blad- effectiveness studies and trials that in- are not generalizable. In men, diabetic auto- clude quality-of-life outcomes are rare, atic review and meta-analysis by the nomic neuropathy may cause erectile so treatment decisions must consider Special Interest Group on Neuropathic dysfunction and/or retrograde ejacula- each patient’s presentation and comor- Pain of the International Association tion (76). Female sexual dysfunction bidities and often follow a trial-and-error for the Study of Pain found the evidence occurs more frequently in those with approach. Given the range of partially ef- supporting the effectiveness of tapenta- diabetes and presents as decreased sex- fective treatment options, a tailored and dol in reducing neuropathic pain to be ual desire, increased pain during inter- stepwise pharmacologic strategy with inconclusive (88). Therefore, given the course, decreased sexual arousal, and careful attention to relative symptom im- high risk for addiction and safety concerns inadequate lubrication (80). The therapeutic goal is to minimize putations can delay or prevent adverse c All patients with diabetes should postural symptoms rather than to restore outcomes. Dietary changes may be pinprick, temperature, vibration, or Clinicians are encouraged to review useful, such as eating multiple small meals ankle reflexes), and vascular assess- American Diabetes Association screen- and decreasing dietary fat and fiber intake. B and practical descriptions of how to per- gastrointestinal motility including opioids, c Patients who are 50 years or older form components of the comprehensive anticholinergics, tricyclic antidepressants, and any patients with symptoms foot examination (105). C All adults with diabetes should undergo paresis, pharmacologic interventions are c A multidisciplinary approach is rec- a comprehensive foot evaluation at needed. Foot inspections paresisisweak,andgiventheriskforserious c Refer patients who smoke or should occur at every visit in all patients adverse effects (extrapyramidal signs such as who have histories of prior lower- with diabetes. C tegrity and musculoskeletal deformities c Provide general preventive foot should be performed. Vascular assess- Erectile Dysfunction self-care education to all patients ment should include inspection and pal- Treatments for erectile dysfunction may with diabetes. B ally, the 10-g monofilament test should may improve the patient’s quality of life. S96 Microvascular Complications and Foot Care Diabetes Care Volume 40, Supplement 1, January 2017 Evaluation for Peripheral Arterial neuroarthropathy is the best way to pre- 8. The routine type 1 diabetes in the Diabetes Control and history of decreased walking speed, leg prescription of therapeutic footwear is Complications Trial and the Epidemiology of Di- fatigue, claudication, and an assessment not generally recommended. Ankle-brachial index patients should be provided adequate in- Diabetes Care 2010;33:1536–1543 testing should be performed in patients formation to aid in selection of appropriate 9. General footwear recommenda- in patients with type 2 diabetes and renal dis- tions include a broad and square toe box, ease: a meta-analysis. Diabetologia 2013;56: Patient Education laces with three or four eyes per side, pad- 457–466 All patients with diabetes and particu- ded tongue, quality lightweight materials, 10. Albuminuria changes and and sufficient size to accommodate a cush- (history of ulcer or amputation, defor- cardiovascular and renal outcomes in type 1 di- ioned insole. Clin J Am Soc footwear can help reduce the risk of future Nephrol 2016;11:1969–1977 should be provided general education foot ulcers in high-risk patients (106,108). Effect of inten- about risk factors and appropriate man- Most diabetic foot infections are poly- sive diabetes treatment on albuminuria in agement (107). Patients at risk should type 1 diabetes: long-term follow-up of the Di- microbial, with aerobic gram-positive understand the implications of foot de- abetes Control and Complications Trial and cocci. Wounds without evidence of soft- nol 2014;2:793–800 care; and the importance of foot moni- tissue or bone infection do not require 12. N Engl J therapy can be narrowly targeted at substitute other sensory modalities Med 2011;365:2366–2376 gram-positive cocci in many patients 13. Effect of intensive blood-glucose control unbreakable mirror) for surveillance of for infection with antibiotic-resistant with metformin on complications in overweight early foot problems. Lan- organisms or with chronic, previously The selection of appropriate footwear cet 1998;352:854–865 treated, or severe infections require and footwear behaviors at home should 14. Patients’ understand- be referred to specialized care centers phonylureas or insulin compared with conven- ing of these issues and their physical (109). Patients with cet 1998;352:837–853 or vascular surgeon, or rehabilitation spe- visual difficulties, physical constraints pre- 15. Intensivebloodglucose con- venting movement, or cognitive problems of individuals with diabetes (109). N Engl J Med 2008;358:2560– dition of the foot and to institute appro- 2572 References priate responses will need other people, 1. Treatment cal practice guideline for the evaluation and man- Lancet 2010;376:419–430 People with neuropathy or evidence of 17. Kidney Int of blood-pressure lowering and glucose control in increased plantar pressures (e. Clin Biochem shoes or athletic shoes that cushion the Renal hemodynamic effect of sodium-glucose Rev 2016;37:17–26 feet and redistribute pressure. Ann Intern Med 2003;139:137–147 pagliflozin and progression of kidney disease in 5. Canagliflozinslowspro- commercial therapeutic footwear, will re- the United States. Re- Liraglutide and cardiovascular outcomes in type 2 hot, swollen foot or ankle, and Charcot nal insufficiency in the absence of albuminuria and diabetes. N Engl J pies on retinopathy progression in type 2 diabe- ney Dis 2015;66:441–449 Med 2004;351:1952–1961 tes. Effects of treatment approach, and glycated haemoglobin of diabetic nephropathy in patients with type 2 di- prior intensive insulin therapy and risk factors concentration on the risk of severe hypoglycae- abetes. N Engl J Med 2001;345:870–878 on patient-reported visual function outcomes in mia: post hoc epidemiological analysis of the 40. 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