I need these questions answered in 150 words each with individual references

UNIT 3

DQ1

Differentiate between bias and confounding. Discuss the criteria necessary to establish a factor as a confounder and provide an example applying these criteria. What is one way to adjust for a confounding relationship in the study design or the analysis?

DQ2

Explain the two major types of bias. Identify a peer-reviewed epidemiology article that discusses potential issues with bias as a limitation and discuss what could have been done to minimize the bias (exclude articles that combine multiple studies such as meta-analysis and systemic review articles). What are the implications of making inferences based on data with bias? Include a link to the article in your reference.

STUDY MATERIALS

Read Chapters 14 and 15 in Gordis Epidemiology.

Read “Association or Causation: Evaluating Links Between ‘Environment and Disease,'” by Lucas and McMichael (2005), located on the World Health Organization website. URL: https://www-ncbi-nlm-nih-gov.lopes.idm.oclc.org/pmc/articles/PMC2626424/pdf/16283057.pdf

Read “Weak Associations in Epidemiology: Importance, Detection, and Interpretation,” by Doll, from Journal of Epidemiology (1996). URL: https://www.jstage.jst.go.jp/article/jea1991/6/4sup/6_4sup_11/_pdf

Read “Causal Inference Based on Counterfactuals,” by Hofler (2005), located on the BioMed Central website. URL: https://bmcmedresmethodol.biomedcentral.com/articles/10.1186/1471-2288-5-28

Read “Multicausality: Confounding,” by Schoenbach (2004), located on the Epidemilog.net website. URL: http://www.epidemiolog.net/evolving/Multicausality-Confounding.pdf

View “Sensitivity and Specificity – Explained in 3 Minutes,” by Martin (2014), located on the YouTube website. URL: https://www.youtube.com/watch?v=FnJ3L-63Cf8

View “The Relationship Between Incidence and Prevalence,” by Patwari (2013), located on the YouTube website. URL: https://www.youtube.com/watch?v=1jzZe3ORdd8

Use the “Creating a 2×2 Contingency Table” resource to assist with the completion of the Measuring Morbidity: Prevalence and Incidence assignment, as needed.

UNIT 4

DQ1

Based on the “Multicausality: Confounding – Assignment,” by Schoenbach, discuss two significant insights you learned about confounding. Use specific examples from the assignment to support your answer.

DQ2

Describe the characteristics and design of a cohort study. Based on a disease or health condition identified from the “2020 LHI Topics” on the Healthy People 2020 website, or an article from the GCU library, discuss a real example of a cohort study (include the link to the article in your post to the forum). Include the participants, exposures or treatment groups, timeframe, and outcomes that were measured. Why is a cohort study described as an “observational” study rather than an “experimental” study design?

STUDY MATERIALS

Read Chapters 7-9 in Gordis Epidemiology.

View “Randomized Control Trials and Confounding,” by Martin (2013), located on the YouTube website. URL: https://www.youtube.com/watch?v=7ybuE39BpQ8

Read “2020 LHI Topics,” located on the Healthy People 2020 website. URL: https://www.healthypeople.gov/2020/leading-health-indicators/2020-LHI-Topics

Complete the “Multicausality: Confounding – Assignment,” by Schoenbach (2001), located on the Epidemilog.netwebsite. URL: http://www.epidemiolog.net/evolving/ConfoundingAssgt.pdf

Refer to the “Multicausality: Confounding – Assignment Solutions,” by Schoenbach (2001), located on the Epidemilog.netwebsite, to check your answers to the assignment. URL: http://www.epidemiolog.net/evolving/ConfoundingSolns.pdf

Read “Understanding Controlled Trials: Why Are Randomized Controlled Trials Important?” by Sibbald and Roland, from British Medical Journal (1998). URL:http://search.proquest.com.lopes.idm.oclc.org/docview/1777585669/fulltextPDF/2BDCED02960C4E6APQ/1?accountid=7374

UNIT 5

DQ1

Describe the common characteristics and design of a case-control study. Discuss the three important features when it comes to selecting cases and controls, and identify a situation when one of these might be violated. Discuss the limitations of using questionnaires for determining exposure status and provide examples of alternative strategies for collecting this information in a case-control study.

DQ2 

Discuss the strengths and weaknesses of cross-sectional studies and examples of how they can be “descriptive” or “analytic” study designs. Discuss an example of a disease where survival could influence the association between a possible exposure and the disease when measured with a cross-sectional study. Do not discuss examples used in the textbook.

STUDY MATERIALS

Read Chapter 10 in Gordis Epidemiology.

View “Cohort and Case Control Studies,” by Martin (2013), located on the YouTube website. URL: https://www.youtube.com/watch?v=J3GHTYa-gZg

Read “Introduction to Study Designs – Cross-Sectional Studies,” located on the Health Knowledge website. URL: https://www.healthknowledge.org.uk/e-learning/epidemiology/practitioners/introduction-study-design-css

Read “Cross-Sectional Studies,” from ERIC Notebook (2012), located on the Gillings School of Global Public Health -University of North Carolina website. URL: https://sph.unc.edu/files/2015/07/nciph_ERIC8.pdf

Read “Section 7: Analytic Epidemiology,” from Lesson 1 of the Centers for Disease Control and Prevention (CDC) self-study course, Principles of Epidemiology in Public Health Practice: An Introduction to Applied Epidemiology and Biostatistics (2012), located on the CDC website. URL: https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section7.html

UNIT 6

DQ1

Differentiate between association and causation using the causal guidelines. Discuss which of the guidelines you think is the most difficult to establish. Discuss the four types of causal relationships and use an example not listed in the textbook to describe each relationship.

DQ2

Explain the difference between relative risk, attributable risk, and population attributable risk. Provide an example (not from the textbook) of how each type of risk is used in epidemiology. How would you propose using population attributable risk to advocate for a health policy or intervention relative to your health interest?

STUDY MATERIALS

Review Chapter 14, and read Chapters 11-13 in Gordis Epidemiology.

Read “Causation in Epidemiology: Association and Causation,” located on the Health Knowledge website. URL: https://www.healthknowledge.org.uk/e-learning/epidemiology/practitioners/causation-epidemiology-association-causation

Read “Section 5: Measures of Association,” from Lesson 3 of the Centers for Disease Control and Prevention (CDC) self-study course, Principles of Epidemiology in Public Health Practice: An Introduction to Applied Epidemiology and Biostatistics (2012), located on the CDC website. URL: https://www.cdc.gov/csels/dsepd/ss1978/lesson3/section5.html

Use the “BRFSS Web Enabled Analysis Tool,” located on the Centers for Disease Control and Prevention (CDC) website, to complete the topic assignment. URL: https://nccd.cdc.gov/weat/#/

Review “Multicausality: Confounding,” by Schoenbach (2004), located on the Epidemilog.net website. URL: http://www.epidemiolog.net/evolving/Multicausality-Confounding.pdf

View “How to Calculate Relative Risk,” by Shaneyfelt (2012), located on the YouTube website. URL: https://www.youtube.com/watch?v=xk2uK14eHNs

View “How to Calculate an Odds Ratio,” by Shaneyfelt (2012), located on the YouTube website. URL: https://www.youtube.com/watch?v=ITi0SxmQTO8

UNIT 7

DQ1

Epidemiological methods are used in a variety of public health areas (including infectious disease, chronic disease, and social health) and settings (including the community, schools, and the workplace). Epidemiological methods are used to assess, describe, analyze, and make comparisons of populations to inform evidence-based practices, policies, and interventions. Propose a study based on the methods you have learned thus far designed to investigate an association within one of the public health areas listed (infectious disease, chronic disease, or social health) and the methods you would apply. Discuss and define the risk factor or exposure that is being assessed, the method of comparison that is used, and the setting or situation (community, school, workplace, etc.) your study would look to address. Consider the concepts of causal inference, measures of association, and study design.

DQ2

Race is often used as a descriptor of disease burden and helps us to determine where health disparities exist in order to address them, which is important. It is helpful to differentiate between race as a descriptor and race as a risk factor. Think about institutional racism and its influence on health. Consider the factors related to race and ethnicity that might be influencing disease status more than the genetics of race when answering this discussion question.

Consider the following statement: “Race is not a risk factor and should not be used in public health data collection.” Discuss the ethical and public health implications of this statement. When might collecting data on race perpetuate institutional racism leading to health disparities and when is it necessary to improve public health? Provide support and examples for your answer. Consider ethical issues related to respect for persons, beneficence, and justice as described in “The Belmont Report.”

STUDY MATERIALS

Read Chapters 17, 19, and 20 in Gordis Epidemiology.

Read “Health Inequalities Among British Civil Servants: The Whitehall II Study,” by Marmot and Smith, from The Lancet (1991). URL:https://lopes.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=hch&AN=9107080526&site=ehost-live&scope=site

Read “The Role of Epidemiology in Disaster Response Policy Development,” by Thorpe et al., from Science Direct (2015). URL:http://www.sciencedirect.com.lopes.idm.oclc.org/science/article/pii/S1047279714003184?_rdoc=1&_fmt=high&_origin=gateway&_docanchor=&md5=b8429449ccfc9c30159a5f9aeaa92ffb

Read “Prescription Drug Abuse: From Epidemiology to Public Policy,” by McHugh, Nielsen, and Weiss, from Journal of Substance Abuse Treatment (2015). URL:http://www.sciencedirect.com.lopes.idm.oclc.org/science/article/pii/S0740547214001871?_rdoc=1&_fmt=high&_origin=gateway&_docanchor=&md5=b8429449ccfc9c30159a5f9aeaa92ffb&ccp=y

Read “The Role Epidemiology in Evidence-Based Policy Making: A Case Study of Tobacco Use in Youth,” by Aldrich et al., from Annals of Epidemiology (2015). URL:http://www.sciencedirect.com.lopes.idm.oclc.org/science/article/pii/S1047279714001495?_rdoc=1&_fmt=high&_origin=gateway&_docanchor=&md5=b8429449ccfc9c30159a5f9aeaa92ffb

Read “Epidemiology, Policy, and Racial/Ethnic Minority Health Disparities,” by Carter-Pokras et al., from Annals of Epidemiology (2012). URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3724931/

Read “Epidemiology and Public Policies,” by Barata, from Revista Brasileira de Epidemiologia (2013). URL: http://www.scielo.br/scielo.php?pid=S1415-790X2013000100003&script=sci_arttext&tlng=en

Read “Ethical Issues in Epidemiologic Research and Public Health Practice,” by Coughlin, from Emerging Themes Epidemiology (2006). URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1594564/

Explore the “Viral Hepatitis Epidemiologic Profiles” map, located on the Association of State and Territorial Health Officials (ASTHO) website, to assist with topic assignment.URL: https://www.astho.org/Viral-Hepatitis-Epi-Profiles/Map/

Use the “BRFSS Web Enabled Analysis Tool,” located on the Centers for Disease Control and Prevention (CDC) website, to complete the topic assignment. URL: https://nccd.cdc.gov/weat/#/

Review the “Belmont Report,” by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1979), located on the U.S. Department of Health and Human Services – Office for Human Research Protections website. URL: https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/index.html

Explore the resources on “Health Data Tools and Statistics,” located on the PHPartners website. URL: https://phpartners.org/health_stats.html

Explore “Surveillance, Epidemiology and the End Results Program,” from the National Cancer Institute.URL: https://seer.cancer.gov/

Explore the STEPwise Approach to Surveillance (STEPS) page of the World Health Organization (WHO) website. URL: http://www.who.int/chp/steps/en/

UNIT 8

DQ1

One method to investigate gene-environment interactions is to study monozygotic twins. Identify an example of a twin study not listed in the textbook used to examine the gene-environment interaction of a specific disease or condition. Briefly summarize the gene-environment interaction investigated, the methods, and the results. What are other possible methods for studying gene-environment interactions as they relate to improving population health?

DQ2

Using the CDC Wonder website, set the query criteria for pancreatic cancer for the United States as illustrated below. Compare the rates by race for Wisconsin and Colorado. Discuss possible biological, genetic, and environmental reasons for differences. What are potential social determinants that contribute to the disparity presented between the two states?

Use this query upon entering the CDC Wonder website:

Select “Cancer Statistics” under the Wonder Systems tab

Select “Cancer Incidence 1999 – 2013” and click “Data Request”

Organize table layout:

1. Group      results by 1. States and 2. Race (leave the rest of the group options as      “None”)
2. Measures      – click “Count” (default) and “Age Adjusted Rates”

Select location – select “States” and “The United States”

Select year and demographics

1. Year      – 2014
2. Sex      – All genders
3. Age      groups – All ages
4. Ethnicity      – All ethnicities
5. Race      – All races

Select cancers of interest – select “Pancreas”

Other options – keep default settings

STUDY MATERIALS

Read Chapter 16 in Gordis Epidemiology.

Read “Gene-Environment Interaction,” located on the National Institute of Environmental Health Sciences website. URL: https://www.niehs.nih.gov/health/topics/science/gene-env/index.cfm

Read “Defeating the ZIP Code Health Paradigm: Data, Technology, and Collaboration Are Key,” by Graham, Ostrowski, and Sabina, from the Health Affairs Blog (2015), located on the Health Affairs website. URL: http://healthaffairs.org/blog/2015/08/06/defeating-the-zip-code-health-paradigm-data-technology-and-collaboration-are-key/

Explore the CDC Wonder page of the Centers for Disease Control and Prevention (CDC) website.URL: https://wonder.cdc.gov/

Review the Mapping Life Expectancy page of the Robert Wood Johnson Foundation website. URL: http://www.rwjf.org/en/library/articles-and-news/2015/09/city-maps.html

Please See Attachment for Case Study and Soap Note Template 

Internal Medicine 08: 55-year-old male with chronic disease management

User: Beatriz Duque

Email: [email protected] Date: October 2, 2020 10:29PM

Learning Objectives

The student should be able to:

List the major causes of morbidity and mortality in diabetes mellitus.

Recognize the basic management of hypertension and hyperlipidemia in the diabetic patient. Perform a diabetic foot exam.

Counsel patient on behavior change.

Recognize value of a team approach to the management of diabetes.

Appreciate the impact diabetes mellitus has on a patient’s quality of life, well-being, ability to work, and the family.

Knowledge

Hypoglycemia

It is important at each visit to ask diabetic patients if they have experienced any hypoglycemic symptoms or events that required the assistance of another person.

Often times, when a patient is hypoglycemic, he does not write it down because he is preoccupied treating the hypoglycemia.

Diabetic Neuropathies

It is estimated that 50% of patients with diabetes will eventually struggle with one or more neuropathies related to their diabetes.

Axonal loss and atrophy are responsible for the majority of clinical symptoms and loss of function in patients with neuropathy. There can also be evidence of demyelination and remyelination, with the actual number of large nerve fibers being reduced, while small nerve fibers increase.

Distal polyneuropathy

Distal polyneuropathy is the most common type of diabetic neuropathy. It is the progressive loss of sensation in the classic stocking/glove distribution. Diabetic foot ulcer incidence is greatly increased in patients with distal polyneuropathy.

Autonomic neuropathy

Autonomic neuropathy can take many forms and affect one or many organs. Specific types include:

cardiovascular (orthostatic hypotension, resting sinus tachycardia, postprandial hypotension) gastrointestinal (gastroparesis, chronic constipation, esophageal motility disorders) genitourinary (sexual dysfunction, neurogenic bladder) abnormal pupillary responses and disorders of hidrosis

Diabetic Retinopathy

Diabetic retinopathy, a microvascular diabetic complication, is the leading cause of preventable blindness in the developed world.

Prevention

Two large prospective trials (DCCT with Type 1 diabetics and UKPDS with Type 2 diabetics) revealed that intensive glucose management resulted in prevention or delayed onset and progression of diabetic retinopathy.

Coexisting hypertension, nephropathy, and tobacco abuse also contribute to retinopathy onset and progression.

Two types of diabetic retinopathy

1.  Non-proliferative diabetic retinopathy

Involves cotton wool spots, hard exudates, microaneurysms, and retinal hemorrhages.

Vision loss usually results from severe macular edema, a thickening of the retina with resultant edema of the macula.

2.  Proliferative diabetic retinopathy

Involves neovascularization of the retinal vessels or optic disc, retinal hemorrhage (dot-blot, flame), retinal fibrosis with traction detachment, and vitreous hemorrhage. Macular edema can occur as well.

Image of proliferative retinopathy with neovascularization

Onset

Development of diabetic retinopathy is directly related to disease duration and is generally not seen in patients who have had diabetes less than five years. The exception is Type 2 diabetic patients who were likely hyperglycemic more than five years prior to their diabetes diagnosis.

Screening

Annual dilated eye exams by an ophthalmologist are recommended for all Type 1 diabetic patients within five years of diagnosis and shortly after diagnosis in patients with Type 2 diabetes. Patients with progressive retinopathy are often seen quarterly or biannually.

Panretinal Treatment

Panretinal laser photocoagulation is the treatment of choice for proliferative diabetic retinopathy and severe cases of nonproliferative retinopathy. Screening is done aggressively due to the well-documented efficacy of laser photocoagulation in the prevention of vision loss. Ranibizumab, an anti-vascular endothelial growth factor, injected into the vitreous showed noninferiority to laser therapy and can also be used.

Diabetic Nephropathy

Epidemiology

Diabetic nephropathy occurs in 20% to 40% of diabetic patients and is the most common etiology of end-stage renal disease in the U.S.

Risk factors associated with the progression of diabetic nephropathy include: obesity, increasing age, African American race, and tobacco abuse.

Pathogenesis

Kidney insult appears to originate with glomerular hypertension and hyperfiltration. Chronic hyperglycemia leads to mesangial expansion, deposition of matrix, increased amount of VEG-F and other cytokines, local inflammation, and activation of protein kinase C.

Prevention / Treatment

Two large prospective trials (DCCT with type 1 diabetics and UKPDS with Type 2 diabetics) revealed that intensive glucose management resulted in prevention or delayed onset and progression of diabetic nephropathy.

Aggressive blood pressure lowering is critical for treatment of increased urinary albumin excretion. In patients with hypertension with increased urinary albumin excretion, an ACE inhibitor or ARB therapy is recommended to delay the onset and decrease progression of diabetic nephropathy.

Referral

Referral to nephrology is appropriate if the cause of kidney disease is not certain, and or there are challenging management issues present, such as resistant hypertension or electrolyte derangement. The threshold for referral to nephrology varies across providers; however, nephrology should be consulted if Stage 4 or greater chronic kidney disease (GFR < 30 ml/min per 1.73 m2) develops since this has been found to reduce cost, improve quality of care, and keep people off dialysis longer.

Diabetes Patient Resources in Spanish

The ADA website has excellent resources for Spanish-speaking patients and their families.

When to Perform the Diabetic Foot Exam

It is important to do a thorough foot exam in a diabetic patient on an annual basis for low-risk patients and more often in patients at high risk for foot ulcer formation.

Patients at High Risk for foot Ulcer Formation

Patients with known diabetic polyneuropathy, sensory or vascular deficits, patients who smoke, and patients with a prior history of diabetic foot ulcer or amputation.

Foot Exam in Patients with Diabetes

Visually inspect the feet for callus formation, ulceration, nail infections, and bony deformities.

Assess skin integrity, especially between toes and under metatarsal heads.

Palpate the dorsalis pedis and posterior tibialis pulses to screen for peripheral vascular disease and look for signs of peripheral

Clinical Skills

vascular disease, such as hair loss.

Check sensation using a 128 Hz tuning fork (vibration) and a cool metal object, potentially the same tuning fork (temperature).

Check pressure sensation using a 10-g monofilament:

Show the monofilament to the patient and try it on their hand to show them it will not hurt.

Ask the patient to close their eyes or look at the ceiling and tell you each time they feel the monofilament touch their foot.

Randomly place the end of the monofilament on the 9 different areas of the foot (see image to the right) with enough pressure to bend the monofilament.

If the patient does not say “yes” at a particular site, continue to the next site and re-test that site at the end.

Check Achilles reflexes.

Effectiveness of Intravenous Insulin for Blood Glucose Control

Blood sugar control in critically ill patients has been the subject of considerable investigation. Previous research suggested that tight control (80-120 mg/dL) was desirable, but more recent research shows that aggressive blood sugar control can be associated with higher mortality.

Hypoglycemia (serum glucose concentration <70 mg/dL), with rates as high as 40% in some studies, is associated with tight glycemic control. A meta-analysis of 29 controlled trials involving more than 8,000 adult ICU patients showed no difference in inhospital mortality between the group assigned to tight glucose control versus usual care.

The current recommended blood glucose target for most hospitalized patients is 140 to 180 mg/dL.

Thiazolidinediones

Pioglitazone (D), a member of the class of drugs known as thiazolidinediones (TZD), is not recommended for use in patients who have newly developed heart failure and in those with known NYHA Class III and IV heart failure. The same is true for rosiglitazone, another TZD that has been associated with an increased risk of cardiovascular disease.

Management

Diabetes Chronic Disease Management

Evaluate for and optimize prevention of diabetic complications

Macrovascular complications:

Cardiovascular disease

Cerebrovascular disease

Microvascular complications:

Retinopathy

Nephropathy

Neuropathy

In particular, cardiovascular disease is the No. 1 cause of mortality for people with diabetes, and one of the top causes of morbidity.

Hypoglycemia, infections, foot ulcers, and amputations are additional causes of morbidity and mortality in patients with diabetes.

The American Diabetes Association publishes annual guidelines to assist in the management of a patient with diabetes.

Remember the large role that the psychosocial aspects of a diabetes diagnosis play in management

Non-adherence with medical recommendations could be due to economic, work-related, religious, social, or linguistic barriers to care. Care must be taken to assess the psychosocial status of each person with diabetes at each clinic visit to ensure that barriers to successful diabetes care are minimized.

ADA Recommendations to Minimize the Risk of Cardiovascular Disease in Patients with Diabetes

Smoking cessation, daily aspirin, blood pressure control, and lipid control are all recommended to reduce the risk of cardiovascular disease.

Please note that as of 2018, ADA recommendations were published with the older definition of hypertension (140/90). It always takes time before multiple different organizations agree on the same thresholds.

Daily low dose aspirin is recommended for primary prevention of cardiovascular disease in diabetic patients with a 10-year risk of atherosclerotic cardiovascular disease of >10%. It is also recommended for secondary prevention of all diabetic patients with a history of atherosclerotic disease.

Reduction of cardiovascular risk is achieved with a goal of optimal glycemic control, as well as control of many other health factors that raise cardiovascular risk, such as tobacco use, obesity, poorly controlled hypertension, and hypercholesterolemia.

Mechanism of action: TZDs are peroxisome proliferator-activated receptor-gamma (PPARgamma) agonists.

Effects: TZDs decrease insulin resistance, increase glucose uptake in peripheral tissue, decrease hepatic glucose production, decrease vascular inflammation, redistribute visceral adipose tissue peripherally, and preserve beta cell function. Overall, they cause the A1c to decrease by 1% to 1.5%. Hypoglycemia is not associated with this medication class. TZDs have differing effects on lipids. Pioglitazone slightly reduces LDL levels and raises HDL. Rosiglitazone can increase LDL levels.

Side effects: The receptors that TZDs activate are ubiquitous and are abundant in the cells within the renal collecting tubules. Hence, TZDs increase sodium reabsorption, leading to increased water retention. Compared to placebo, all TZDs are associated with a statistically significant increase in edema and weight.

Warnings: Care should be used with these agents in patients with liver disease. Serum transaminases greater than 2.5 times the upper limit of normal is a contraindication to initiation of these agents, and a rise to greater than three times the upper limit of normal should lead to their discontinuation. Liver tests should be measured at baseline and periodically while the patient is on this class of medication.

Contraindications: The FDA has added a warning to the label of pioglitazone noting an increased risk of bladder cancer after more than one year of treatment. Pioglitazone is now contraindicated in patients with a history of bladder cancer or active bladder cancer. Patients should be counseled to tell their physician if they notice blood in their urine or a red tint to their urine.

When to Refer Patients with Diabetes to an Endocrinologist

If a patient is having recurrent or severe hypoglycemia (seizure, coma, or impairment that requires the aid of another person), an endocrinologist should be consulted. Hypoglycemia is defined as a blood glucose <70 mg/dL.

Primary care physicians’ threshold for referral varies across providers. Other conditions that would warrant referral are when a patient’s A1c is 8% more than twice in a 12-month period, despite intensive treatment; for initiation of a complex multiple daily injection insulin regimen; or for initiation of continuous infusion insulin pump therapy.

Self-Monitoring Glucose: Indications & Effectiveness

Effectiveness of Self-Monitoring Blood Glucose

Patients should be advised to check their blood sugar if they feel “low” because it is well recognized that people are not able to accurately detect hypoglycemia (blood glucose of < 70 mg/dL) by symptoms alone. Eating high carbohydrate food to treat perceived hypoglycemia rather than actual hypoglycemia leads to worsened overall glycemic control.

Clinical studies have shown that self-monitoring of blood glucose (SMBG) may improve glycemic control, although for some patients self-monitoring increases depression and anxiety. It is important to evaluate patients’ abilities to use SMBG techniques to ensure they are using accurate data to evaluate their response to therapy and their degree of success in reaching blood-glucose targets. After receiving education, patients can use SMBG data to adjust their activity level, food intake and choice, as well as drug therapy to achieve optimal glycemic control.

When to Self-Monitor Blood Glucose

In patients on less frequent insulin injections, SMBG may be useful in achieving glycemic goals.

Patients on an insulin pump and those using multiple daily insulin injections should self-monitor blood glucose at the following times:

before each meal at bedtime

when they have symptoms of hyper- or hypoglycemia after treating hypoglycemia to ensure return of euglycemia before exercise

before critical activities, such as driving

Blood Glucose Goals

Healthy Adults

*Medically Complex

Adults

**Very Medically Complex

Adults

fasting and before meals

80-130 mg/dL (3.9-7.2 mmol/L)

90-150 mg/dL

100-180 md/dL

one to two hours after a meal

< 180 mg/dL (10.0 mmol/L)

before bed

100-130 mg/dL (5.6-7.2 mmol/L)

100-180 mg/dL

110-200 mg/dL

*Medically complex adults have multiple coexisting chronic illnesses, two or more ADL impairments, or mild to moderate cognitive impairment.

**Very medically complex adults or adults in poor health have long term care or end-stage chronic illnesses, moderate to severe cognitive impairment, or two or more ADL dependencies.

Foot Care for Patients with Diabetes

It is important to review and provide information about foot self-care with diabetic patients.

Patients should be instructed to check the dorsal and plantar surfaces of their feet everyday for cuts, sores, redness, and swelling.

See the associated reference ranges in conventional and SI units.

Body Weight Management in Patients with Diabetes

Classification

BMI in kg/m2

Normal

19-24

Overweight

25-29

Obese

30-39

Morbidly obese

40+

Maintenance of a healthy body weight is essential in the management of patients with diabetes. However, for some patients, attainment of an ideal body weight is too large a goal, especially if they are morbidly obese. Studies have shown that a modest weight loss of approximately 5-10% of the current weight can lead to significant improvement in glycemic control, blood pressure control, and lipid parameters.

Multidisciplinary Approach to Diabetes Care

The care of the patient with diabetes is a team endeavor. Through a multidisciplinary approach, patients can be offered the very best chance of optimizing their blood glucose control and reducing their risks of morbidity and mortality.

Refer to a registered nutritionist for medical nutrition therapy regarding daily food choices and portion sizes. Refer to an accredited diabetes care center for diabetes management self-education, both in group and one-on-one settings. Numerous studies have shown that diabetes management self-education is effective in improving patients’ selfcare behaviors, lowering their A1c, improving their knowledge of diabetes and enhancing their quality of life.

Office-based counseling of basic ADA recommendations for diet and exercise can be reviewed with the patient. For example, patients can be taught how to monitor his carbohydrate intake through carbohydrate counting, food exchanges, or selfreflection. Thirty minutes of moderately intense exercise, more days than not, may be a good recommendation for many patients. Less than 10% of daily calories should be from fat.

Patient education materials are a useful adjunct to office-based counseling, and can be found at the ADA website section on diet/exercise.

Blood Pressure Goal for Patients with Diabetes

There is ample, well-validated evidence that blood pressure control is one way of lowering a diabetic patient’s cardiovascular risk. According to the ADA, the optimal blood pressure goal in patients with diabetes is less than 140/90 mmHg. Younger, healthier patients who can be treated without increasing the treatment burden may have a lower systolic target, such as less than 130. It is important to remember that an individual patient’s blood pressure goal may be higher or lower based on his/her response to therapy and personal characteristics. Note: Other organizations recommend different blood pressure goals for patients with diabetes, such as the ACC/AHA, which recommends treatment in people with diabetes who have blood pressure greater than or equal to 130/80 mmHg, with a goal blood pressure of less than 130/80 mmHg.

The ACC/AHA guidelines on hypertension published in late 2017 suggested lower numbers for a definition of HTN; now anything over 130/80 is considered hypertension per ACC/AHA. Other organizations – like ADA – have not yet updated their guidelines to reflect this change.

Pharmaceutical management

Most diabetic patients require multiple agents to reach and maintain their individual blood pressure goal. ACE inhibitor and ARB therapy are first-line treatment options because they also delay the onset and decrease the progression of diabetic nephropathy. Diuretics and calcium channel blockers can be used to attain blood pressure goals.

Reasons for uncontrolled blood pressure

There are multiple reasons why a patient may have uncontrolled blood pressure. Blood pressure may be uncontrolled in patients needing increased dosages of their medications or additional agents. It may be elevated secondary to medications (e.g. NSAIDs) or alcohol. Or patients may not be taking their medications regularly, may not have taken their medications on the day of the office visit, or may have run out of their medication prior to the visit.

Before adding another medication or increasing the dose of existing medication, it is critical that nonadherence be explored first as a possible cause of uncontrolled hypertension.

If the patient is unable to view his entire foot by himself, then a caregiver should be asked to do it for him.

Feet should be washed daily and dried well.

Remind patients to use their forearm to check water temperature to prevent burns.

Patients should keep the skin of their feet smooth and soft with lotion.

Toenails should be trimmed weekly or as needed.

Patients should be encouraged to wear white socks, as these will show any drainage from a previously unknown sore, and well-fitting, comfortable shoes.

Shoes and socks should be worn at all times.

There is no robust evidence to warrant the recommendation that all patients with diabetes be fitted with special shoes to prevent diabetic foot ulcers.

High-risk patients should be referred to a podiatrist for comprehensive foot care.

Smoking Cessation in the Setting of Diabetes

Complete smoking cessation is the goal in all patients, and smoking cessation counseling should be part of every clinic visit. Merely asking if the patient is considering smoking cessation increases the chance that the patient will quit. Patients who have already cut down should be congratulated on accomplishing that hard task, then they should be encouraged to build on this success and quit completely.

Studies have shown that diabetic smokers suffer far more cardiovascular comorbidity than patients without diabetes who smoke and that smoking cessation leads to decreased progression of retinopathy and nephropathy.

Vaccinations for Patients with Diabetes

Diabetic patients should receive a pneumococcal vaccination and should be immunized for influenza annually. They should also receive the Hepatitis B vaccine series if they are between 19 and 59 years old.

Dental Care for Patients with Diabetes

Diabetic patients should be seen by a dentist regularly; the recommendation is twice a year.

Metformin Contraindications

Metformin is not recommended for patients with reduced ejection fraction requiring pharmacologic therapy, in particular patients with unstable or acute heart failure. It is likely safe in patients with well-compensated, stable CHF. It is prudent to stop a patient’s metformin in the setting of a recent heart failure diagnosis but it may also be reasonable to restart it in the future should their symptoms stabilize.

Metformin is also contraindicated in patients with a GFR of < 30 mL/min/1.73m2. In addition, it shouldn't be started in patients with a GFR of 30 to 45 mL/min/1.73m2 though can be continued at a reduced dose with a GFR in this range in patients started on the medication when kidney function was normal. It is also contraindicated in patients with alcohol abuse or marked liver disease. These contraindications exist due to the increased risk of lactic acidosis in these patients. Metformin should be routinely discontinued when patients are hospitalized due to the increased risk of dehydration and opportunity for IV contrast dye use, which could reduce renal function.

Injectable Medications for Type 2 Diabetes

Insulin

Different types of insulin are used to manage diabetes.

The ADA Standards of Medical Care in Diabetes state, “consider initiating insulin therapy (with or without additional agents) in patients with newly diagnosed Type 2 diabetes who are symptomatic and/or have A1c 10% or greater and/or blood glucose levels

300 mg/dL or greater.”

Evidence is accumulating that earlier use of insulin in the treatment of patients with uncontrolled Type 2 diabetes results in better long-term glycemic control. In a patient with an A1c value 9% or greater, oral hypoglycemic and non-insulin injectable medications as monotherapy are unlikely to bring the patient’s A1c to goal, and dual therapy is recommended.

When insulin is used, typically a basal insulin, such as glargine or detemir, is initiated first, with continuation of one or more oral medications (usually metformin, unless there is a contraindication). The regimen is then escalated every three to six months until the A1c goal is attained.

In patients on a single oral agent whose A1c is within one percentage point of goal, adding another oral agent or non-insulin injectable should be considered. A well-known meta-analysis found that for each non-insulin agent added from a different class, the A1c could be expected to decrease 0.9-1.1%.

For a comprehensive list of available insulins refer to table 8.2: Pharmacology of available glucose-lowering agents in the U.S. for the treatment of type 2 diabetes

Glucagon-like peptide-1 receptor agonists

Mechanism of action: There are several GLP-1 receptor agonists available, commonly prescribed agents include exenatide and liraglutide. These agents increase insulin secretion in a blood glucose dependent manner. They also decrease

postprandial glucagon secretion, slow gastric emptying, centrally increase satiety, and decrease appetite.

Administration: These agents are all delivery by subcutaneous injection. There are monthly, weekly, daily and twice daily formulations. They can be used in combination with most oral medications and with basal insulin.

Side effects: The most common side effect is nausea, which can be significant, accompanied by emesis.

Effects: A1c decreases of approximately 1% and statistically significant weight loss are associated with use.

Contraindications: There have been post marketing reports of exenatide-induced pancreatitis, so its use in patients with a history of pancreatitis should be avoided. Tumors of the C-cells have been reported.

Studies

Chronic Diabetes Evaluation

Hemoglobin A1c

Hemoglobin A1c should be ordered every six months in patients who are meeting their individualized treatment goals, and every three months if they are not or if therapy is changing.

An HbA1c goal of < 7% is generally a reasonable goal for a nonpregnant, otherwise healthy adult patient. More stringent A1c goals (< 6.5%) may be appropriate in some patients, with shorter disease duration, long life expectancy, and no significant cardiovascular disease, if it can be attained without significant hypoglycemia.

The ADA Standards of Medical Care in Diabetes state, “less stringent A1c goals (such as < 8%) may be appropriate for patients with history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, and those with longstanding diabetes in whom a stringent goal is difficult to attain." For patients who have limited resources and a poor support system, and/or are unable to prioritize self-care due to social, economic or psychological stressors, a less stringent A1c goal may also be appropriate.

Remember that HbA1c levels are unreliable in patients with hemoglobin variants, such as sickle cell disease; with end-stage kidney failure/on dialysis, and who have recently had blood transfusions or large blood loss. Individuated Hemoglobin A1c Goals

Healthy Nonpregnant Adults, without severe recurrent hypoglycemia/hypoglycemic unawareness

< 7%

Medically Complex Adults, with history of severe hypoglycemia and/or longstanding diabetes

< 8%

Medically Complex Adults/Adults in Poor Health, with severe recurrent hypoglycemia/hypoglycemic unawareness

< 8.5%

Fasting lipid profile

The ADA and the AHA/ACC are overall in agreement regarding lipid management in diabetic patients.

The AHA/ACC guidelines are:

Lifestyle modification (weight loss, increased physical activity, reduced fat intake) should be recommended for all patients with diabetes, where appropriate.

All patients with diabetes and cardiovascular disease, regardless of age, should be on a high intensity statin.

All patients aged 40 to 75 with diabetes should be on a moderate-intensity statin. If ASCVD risk is >7.5%, they should be on a high-intensity statin.

For patients aged <40 or >70 with diabetes, consider statin therapy depending on risks/benefits and patient preferences. The ACC/AHA does not recommend lipid goals at this point.

See the Aquifer Cholesterol Guidelines for more information about this.

Liver function profile

Indicated if the patient takes a TZD. When patients take this class of medication, liver tests should be monitored periodically.

Basic metabolic profile

Indicated to monitor renal function if the patient takes metformin and in patients with diabetes in general.

Spot urine albumin/creatinine ratio

Indicated annually in patients with Type 2 diabetes without evidence of increased urinary albumin excretion (<30 mcg albumin/mg creatinine) and more often to assess for progression and effect of therapy in patients with established increased urinary albumin excretion (30 mcg albumin/mg creatinine or greater). A diagnosis of increased urinary albumin excretion is made when two of three specimens collected within a 3- to 6-month period are 30 mcg/mg creatinine or greater. Remember that vigorous exercise within the last 24 hours, menstruation, illness, fever, markedly elevated blood pressure, CHF exacerbation, and acute hyperglycemia can cause false-positive

For this week’s assignment, you will be considering how news media coverage affects public perceptions of issues in the news. You will be selecting a current event in the news and you will read three news articles related to the same event: One from the United States and two from other countries that also reported on the same event. 

The presentation should include the following:

• Identification of the current event chosen along with identification of the three news articles.  
• Include the full APA citation for each article, including the date it was published and the country it was reported in, and a URL/web link to each source.
• Include screenshots of the first page of each article in your presentation.
• Compare the similarities and differences between the articles in the facts, perspectives of the reporter (tone, opinions shared, etc.).  Consider the way images were used in the article or whether you can detect the reporter’s bias/position in relation to the issue.
• Discuss your perceptions of the current event before and after reading the news articles.  Did your opinion or perception of the event/issue change after reading three articles about it?

In the presentation:

• Provide speaker’s notes or a voice over on the PowerPoint to accompany each slide.  If you choose speaker’s notes, the total word count of your notes should be 1000-1200 words. 
• Include a title slide and include your references page in APA format on the last slide of the presentation.

Submit:

• A 10-12 slide PowerPoint presentation or Prezi that answers the questions posed above. Include speaker notes or a voice-over, images, and videos where applicable.  

Tips on locating articles to use for this assignment:

Choose a current event or issue that you are familiar with in the news today. 

• First: Go to an American news source (such as CNN) and find an article related to the event/issue. 
• Second: Consider what two countries’ news you should look for the issue in. It’s best to select countries that have a social or political interest in the story, countries that are nearby geographically to the news issue, or even countries that are close allies of the country the story relates to. 
• Third: Locate an English language news source for each country by searching online for “English Language news in [country name]”. 

For example:  If you chose a story related to North Korea’s attempts to test nuclear bombs, you might choose China (North Korea’s main ally) and South Korea (North Korea’s main enemy) as two additional countries to read about the event in.

• Fourth: Once you locate an English language news source for that country, locate an article on the same current event and/or global issue.  It’s a good idea to choose an article with a publication date close to your American article to be sure that the same event is being discussed.
• Fifth:  Repeat the previous step for your third article.

 

Health care administration offers many opportunities to work on committees, teams, or special projects in an HCO. Discuss one such environment and what regulatory entity may have jurisdiction over the work product. Include how you would ensure that the needs of accreditation or regulatory compliance are being met if leadership designated as an approving body for your team or committee does not support your product or value. please add in-text citation and reference

 

Competency

Explain principles of care for clients with oncological disorders.

Scenario

Anna is a 45-year-old female that presented to her physician’s office for her annual check-up. Anna has a history of diabetes, obesity, and noncompliance with diet and medications to control her diabetes. She a single mother of three teenagers and smokes regularly. During the history review, Anna shares with you that she has not been feeling like herself for the past six months, she has been unusually tired and thought that she felt a lump in her right breast during a self-breast exam around that same time. She stated, “I am very busy with my children; I haven’t had time to get it checked out.” She has recently been experiencing right nipple pain. Anna has a positive family history of breast cancer; both her mother and grandmother have been treated for breast cancer. Anna has never had a mammogram. During the breast examination, the practitioner palpated a lump in Anna’s right breast. No discharge from the nipple was observed. Anna’s right breast was tender upon palpation. No abnormalities were found in the left breast. Based on the physical findings Anna will undergo a diagnostic mammogram.

Instructions

In a 2-page paper, describe the care that Anna would require and address the questions below.

1. What risk factors does Anna have that could predispose her to the development of cancer?
2. What signs and symptoms could indicate that Anna has developed cancer?
3. Based on Anna’s risk factors and presenting problems, identify three care strategies that you would use to provide quality care to Anna. Provide rationale to explain why you chose these strategies.

Resources

For assistance with citations, refer to the APA Guide.

For assistance with research, refer to the Nursing Research Guide.

discussion board

All nurse managers are tasked with conducting employee evaluations on all units to identify one Full time employee per department that could be asked to move to Part time employee due to budget cuts. The facility continues to lose money, and the hospital board would like to reduce FTE one per unit.

How would the decision grid play a role in assisting the nurse managers to identify the employee who may be asked to move to Part time?

Why is the decision grid pertinent to problem solve this scenario?

How does a nurse manager use a consequence table to assess short- and long-term impact of alternatives? 

Please all of the questions above pertaining to the Case Scenarios.

 

Describe the selected problem from two of the three system levels (micro, meso, macro).

 The healthcare system is a complex and high risk; therefore, the Joint Commission recommends creating high-reliability organizations within every healthcare facility.  Building a high-reliability organization is about creating a culture of high quality, high safety, and patient-focused.  Using my facility as an example, the culture within each of the departments at the hospital is the microsystems level.  This is the location of patient communication and hands-on patient care.  The problem exists in reporting near misses to avoid bigger safety events in the future.  The culture across the Mercy Health St. Rita’s including the hospital, home care/hospice, primary care, and specialty offices would be the mesosystem level.  Here continuity of care is provided across this environment.  Having an environment that promotes communication and reporting is the problem.  The culture among the entire BonSecour Mercy Health healthcare system would be the macrosystems level.  They govern the overall healthcare being provided according to the standards and expectations (Alam, 2020).  The problem would be to establish the expectations around creating a high-reliability organization.

Explain how the outcomes of one system level effect the other levels?

            The culture of one system-level reflects the values and beliefs of team members across all levels.  The expectations from the macrosystem reflection down to the microsystem.  Like with Joint Commission setting an expectation for healthcare systems to become high-reliability organizations, the regulatory team members from the macro to meso to micro enforce these expectations.  The mesosystem level receives most of the attention related to the culture embedded within their organization good or bad.  However, the training and education to create a culture of high safety and quality happen at the microsystem level.  It includes providing an environment where front line team members feel safe to speak about the problems and offer solutions on how to solve them without the fear of repercussion.  The microsystem level needs to know the macrosystem and mesosystem levels will trust and support them (Manley & Jackson, 2019).

How is a systems approach beneficial in improving healthcare quality and safety?

 All workers want to be apart of an organization that promotes high quality and safety no matter the system level they are associated with.  Continuing the focus of creating a culture of high quality and safety, all levels have a different view.  The macrosystem level can see when environments do not promote this culture leading to risk and harm caused to patients.  They see patterns for success and opportunity across various facilities.  Learning from one another can be promoted.  This level is visionary,  big picture.  At the mesosystem level has the view to see the expectations and see the details specific to the facility to create the process around developing the culture.  Middle managers at this level are strategically valuable.  They can effectively influence change through educating and encouraging team members to speak out.  From here they can voice concerns or needs up to the macrosystem level (Gutberg & Berta, 2017).  The microsystem level can implement a culture of high quality and safety.  With training, development, and support, they can carry out the vision set forth by the macrosystem level   (Manley & Jackson, 2019).  All system levels are important for advancing the healthcare system.  Neither level could function independently effectively or efficiently.   

I need a comment for this post at least 2 paragraphs with 2 sources no later than 5 years. 

The Adaptation Model of Nursing is a prominent nursing theory aiming to explain or define the provision of nursing science. In her theory, Sister Callista Roy’s model sees the individual as a set of interrelated systems who strives to maintain a balance between various stimuli.A 23-year-old male patient is admitted with a fracture of C6 and C7 that has resulted in quadriplegia. He was injured during a football game at the university where he is currently a senior. His career as a quarterback had been very promising. At the time of the injury, contract negotiations were in progress with a leading professional football team.

1. Use Roy’s criteria to identify focal and contextual stimuli for each of the four adaptive modes.

2. Consider what adaptations would be necessary in each of the following four adaptive modes: (1) physiological, (2) self-concept, (3) interdependence, and (4) role function.

3. Create a nursing intervention for each of the adaptive modes to promote adaptation.

 

1) Minimum 9 full pages (Follow the 3 x 3 rule: minimum three paragraphs per part)

              Part 1: Minimum 1 page

              Part 2: minimum 1 page

              Part 3: minimum 1 page

              Part 4: minimum 1 page 

              Part 5: Minimum 1 page

              Part 6: minimum 1 page

              Part 7: minimum 1 page

              Part 8: minimum 1 page

              Part 9: minimum 1 page

Submit 1 document per part

2)¨******APA norms

          All paragraphs must be narrative and cited in the text- each paragraphs

          Bulleted responses are not accepted

          Dont write in the first person 

          Dont copy and pase the questions.

          Answer the question objectively, do not make introductions to your answers, answer it when you start the paragraph

         Submit 1 document per part

3)****************************** It will be verified by Turnitin (Identify the percentage of exact match of writing with any other resource on the internet and academic sources, including universities and data banks) 

********************************It will be verified by SafeAssign (Identify the percentage of similarity of writing with any other resource on the internet and academic sources, including universities and data banks)

4) Minimum 3 references per part not older than 5 years

5) Identify your answer with the numbers, according to the question.

Example:

Q 1. Nursing is XXXXX

Q 2. Health is XXXX

6) You must name the files according to the part you are answering: 

Example:

Part 1.doc 

Part 2.doc 

__________________________________________________________________________________

Part 1:

Families may encounter different types of crisis. 

1. Choose one of the family crisis discussed in your textbook and discuss it.

Part 2:

Often in practice, we connect the concept of spirituality with religion, but according to the readings in the text, (chap 15) there are differences.

1. How can nurses incorporate these two concepts (spirituality with religion) into your practice? 

         a. Give at least two examples.

2. Write one of the North American Nursing Diagnosis Association (NANDA) nursing diagnoses related to Sexuality and Intimacy 

       b. Develop two patient-specific interventions for the client.

Part 3:

After viewing the video of the student disagreeing with the grade he received, discuss each of the responses given by the faculty. 

1. In your discussion, include how each response facilitated or hindered the quality of interaction between the instructor and the student. 

2. How would you have handled this situation?

Part 4:

1. Select two essential psychomotor skills and describe them. 

2. What are two strategies you might use to assess the student’s learning outcomes and improve learning?

Part 5:

1. Discuss the steps required to submit research to a professional journal

2 what you feel will be the biggest obstacle about nursing research (Investigation)? Why?

Part  6:

 

Read the following article on the impact of maternal prenatal smoking on the development of childhood overweight in school-aged children from the WCU library: 

http://search.ebscohost.com.westcoastuniversity.idm.oclc.org/login.aspx?direct=true&db=a9h&AN=87709502&site=ehost-live. 

1. Is the article quantitative, qualitative, or something else? 

2. indicate the State the study design, research question, and the strength and limitations of the study. 

3. Can the study results be generalized? Why or why not?

Part  7:

 

Review some nursing journals that deal primarily with education, research, or administration, such as the Journal of Nursing Education, Nursing Research, or the Journal of Nursing Administration, 

1. Discuss the current topics emphasized in these journals.

Part  8:

 

a. Is the use of soap and water or alcohol-based rubs more effective in preventing nosocomial infections?

b. How effective are anti-depressive medications on anxiety and depression?

c . What is the difference in attitudes of male and female college students toward condoms?

Taking into account the 3 previous questions, select and explain the following points for each question:

1. Which is the most appropriate research design.

               Quantitative designs: experimental, quasi-experimental, and nonexperimental, and others…

               Qualitative designs: phenomenology, ethnography, grounded theory, and historical.

2. Discuss and explain  2 strengths and 2 weaknesses of the design selected.

3. Why did you select this type of study? explain and justify your choice

Part 9 :

 

a. How effective are anti-depressive medications on anxiety and depression?

 b. What is the relationship between alcohol and breast cancer?

c . What is the difference in attitudes of male and female college students toward condoms?

Taking into account the 3 previous questions, select and explain the following points for each question:

1. Which is the most appropriate research design.

               Quantitative designs: experimental, quasi-experimental, and nonexperimental, and others…

               Qualitative designs: phenomenology, ethnography, grounded theory, and historical.

2. Discuss and explain  2 strengths and 2 weaknesses of the design selected.

3.  Why did you select this type of study? explain and justify your choice

Considering your selected topic, what healthcare teams would be essential to help support your new project implementation? How would each identified team help support the integration and outcomes you plan to achieve? Consider aspects related to communication, collaboration and professional organizations for best practices in healthcare informatics.