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", metabolic brain disease journal impact factor."

By: Bruce Alan Perler, M.B.A., M.D.

  • Vice Chair for Clinical Operations and Financial Affairs
  • Professor of Surgery

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0002711/bruce-perler

Monitor for fi Orthostatic Hypotension and Syncope: Monitor heart rate and blood clinical worsening and emergence of suicidal thoughts and pressure and warn patients with known cardiovascular or cerebrovascular behaviors diabetic zucchini bread recipes . Suicidal Thoughts and Behaviors Antidepressants increased the risk of suicidal thoughts and behaviors in patients aged 24 years and younger in short-term studies metabolic disease and metabolic syndrome . Monitor closely for clinical worsening and for emergence of suicidal thoughts and behaviors diabetes test blood or urine . Dosage increases should occur at weekly intervals based on the patient’s clinical response and tolerability blood glucose levels for diabetics . Periodically reassess to determine the continued need and appropriate dosage for treatment. Titrate to 2 mg once daily on Day 5 through Day 7, then to 4 mg on Day 8 based on the patient’s clinical response and tolerability. Analyses of 17 placebo-controlled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular. The drug-placebo differences in the number of cases of suicidal thoughts and behaviors per 1000 patients treated are provided in Table 3. There were suicides in the adult studies, but the number was not sufficient to reach any conclusion about antidepressant drug effect on suicide. Table 3: Risk Differences of the Number of Patients with Suicidal Thoughts or Behaviors in the Pooled PlaceboControlled Trials of Antidepressants in Pediatric and Adult Patients Age Range Drug-Placebo Difference in Number of Patients with (years) Suicidal Thoughts or Behaviors per 1000 Patients Treated Increases Compared to Placebo <18 14 additional patients 18 to 24 5 additional patients Decreases Compared to Placebo 25 to 64 1 fewer patient fi65 6 fewer patients It is unknown whether the risk of suicidal thoughts and behaviors in children, adolescents, and young adults extends to longer-term use, i. Monitor all antidepressant-treated patients for clinical worsening and emergence of suicidal thoughts and behaviors, especially during the initial few months of drug therapy and at times of dosage changes. Counsel family members or caregivers of patients to monitor for changes in behavior and to alert the healthcare provider. Additional signs may include elevated creatinine phosphokinase, myoglobinuria (rhabdomyolysis), and acute renal failure. The risk appears to be highest among the elderly, especially elderly women, but it is not possible to predict which patients are likely to develop the syndrome. Whether antipsychotic drugs differ in their potential to cause tardive dyskinesia is unknown. The risk of tardive dyskinesia and the likelihood that it will become irreversible increase with the duration of treatment and the cumulative dose. The syndrome can develop after a relatively brief treatment period, even at low doses. Tardive dyskinesia may remit, partially or completely, if antipsychotic treatment is discontinued. Antipsychotic treatment itself, however, may suppress (or partially suppress) the signs and symptoms of the syndrome, possibly masking the underlying process. The effect that symptomatic suppression has upon the long-term course of tardive dyskinesia is unknown. Chronic antipsychotic treatment should generally be reserved for patients: (1) who suffer from a chronic illness that is known to respond to antipsychotic drugs; and (2) for whom alternative, effective, but potentially less harmful treatments are not available or appropriate. In patients who do require chronic treatment, use the lowest dose and the shortest duration of treatment needed to produce a satisfactory clinical response. Although all of the drugs in the class to date have been shown to produce some metabolic changes, each drug has its own specific risk profile. Hyperglycemia and Diabetes Mellitus Hyperglycemia, in some cases extreme and associated with ketoacidosis or hyperosmolar coma or death, has been reported in patients treated with atypical antipsychotics. Assess fasting plasma glucose before or soon after initiation of antipsychotic medication and monitor periodically during long-term treatment. Combined, 9% of subjects with normal or borderline fasting glucose experienced shifts to high fasting glucose during the long-term depression studies. Combined, 10% of subjects with normal or borderline fasting glucose experienced shifts to high fasting glucose during the long-term schizophrenia studies. Before or soon after initiation of antipsychotic medication, obtain a fasting lipid profile at baseline and monitor periodically during treatment. Of patients with normal baseline triglycerides, 17% experienced shifts to high, and 0. Table 5: Change in Fasting Triglycerides in the 6-Week Placebo-Controlled, Fixed-Dose Schizophrenia Trials Proportion of Patients with Shifts Baseline to Post-Baseline Triglycerides Placebo 1 mg/day 2 mg/day 4 mg/day Normal to High 6% 10% 8% 10% (<150 mg/dL to fi200 and <500 mg/dL) (15/253)* (7/72)* (19/232)* (22/226)* Normal/Borderline to Very High 0% 0% 0% 0. Of patients with normal baseline triglycerides, 13% experienced shifts to high, and 0. In the long-term, openlabel depression studies, 30% of patients demonstrated a fi7% increase in body weight, and 4% demonstrated a fi7% decrease in body weight. Schizophrenia Table 7 shows weight gain data at last visit and percentage of adult patients with fi7% increase in body weight at endpoint from the 6-week placebo-controlled, fixed-dose clinical studies in patients with schizophrenia. Table 7: Increases in Body Weight in the 6-Week Placebo-Controlled, Fixed-Dose Schizophrenia Trials Placebo 1 mg/day 2 mg/day 4 mg/day n=362 n=120 n=362 n=362 Mean Change from Baseline (kg) at Last Visit All Patients +0. In the long-term, open label schizophrenia studies, 20% of patients demonstrated a fi7% increase in body weight, and 10% demonstrated a fi7% decrease in body weight. Other compulsive urges, reported less frequently, include: sexual urges, shopping, eating or binge eating, and other impulsive or compulsive behaviors. In some cases, although not all, urges were reported to have stopped when the dose was reduced or the medication was discontinued. Compulsive behaviors may result in harm to the patient and others if not recognized. Consider dose reduction or stopping the medication if a patient develops such urges. Agranulocytosis (including fatal cases) has been reported with other agents in this class. Monitor patients with clinically significant neutropenia for fever or other symptoms or signs of infection and treat promptly if such symptoms or signs occur. Generally, the risk is greatest during initial dose titration and when increasing the dose. Orthostatic vital signs should be monitored in patients who are vulnerable to hypotension. For patients with diseases, conditions, or medications that could exacerbate these effects, complete fall risk assessments when initiating antipsychotic treatment and recurrently for patients on long-term antipsychotic therapy. This risk is greatest in patients with a history of seizures or with conditions that lower the seizure threshold. Conditions that lower the seizure threshold may be more prevalent in older patients. Dystonia Symptoms of dystonia may occur in susceptible individuals during the first few days of treatment. Dystonic symptoms include: spasm of the neck muscles, sometimes progressing to tightness of the throat, swallowing difficulty, difficulty breathing, and/or protrusion of the tongue. While these symptoms can occur at low doses, they occur more frequently and with greater severity with high potency and at higher doses of first-generation antipsychotic drugs. The following listing does not include adverse reactions: 1) already listed in previous tables or elsewhere in the labeling, 2) for which a drug cause was remote, 3) which were so general as to be uninformative, 4) which were not considered to have clinically significant implications, or 5) which occurred at a rate equal to or less than placebo. Eye Disorders: Vision Blurred Gastrointestinal Disorders: Nausea, Dry Mouth, Salivary Hypersecretion, Abdominal Pain, Flatulence Infections and Infestations: Urinary Tract Infection Investigations: Blood Prolactin Increased Musculoskeletal and Connective Tissue Disorders: Myalgia Psychiatric Disorders: Abnormal Dreams, Insomnia Skin and Subcutaneous Tissue Disorders: Hyperhidrosis 6. For more information contact the National Pregnancy Registry for Atypical Antipsychotics at 1-866-961-2388 or visit womensmentalhealth. The background risk of major birth defects and miscarriage for the indicated population(s) is unknown. Clinical Considerations Fetal/Neonatal Adverse Reactions Extrapyramidal and/or withdrawal symptoms, including agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress and feeding disorder, have been reported in neonates whose mothers were exposed to antipsychotic drugs during the third trimester of pregnancy. Some neonates recovered within hours or days without specific treatment; others required prolonged hospitalization. Monitor neonates for extrapyramidal and/or withdrawal symptoms and manage symptoms appropriately.

Usually diabetes medications linked to pancreatic cancer , able to diabetes type 1 meal plan the expertise acquired for marketing and distribNovartis applies the fair value less costs of disposal uting Alcon surgical products inborn metabolic disease 5th edition . In most cases diabetes symptoms glucose levels , Technologies represent identifed and separable no directly observable market inputs are available to acquired know-how used in the research, development measure the fair value less costs of disposal. In the limited cases where the value in in the “Other” category and amortized once available for use method would be applied, net present value techuse. Marketable securities held for long-term entry of generic competition strategic purposes are classifed as non-current fnan• Outcome of R&D activities (compound efcacy, results cial assets on the consolidated balance sheet. If the • Appropriate royalty rate for the Alcon Brand name market for a fnancial asset is not active or no market is • Appropriate terminal growth rate available, fair values are established using valuation tech• Appropriate discount rate niques. The majority of non-quoted investments are valued initially at fair value through the established purchase Generally, for intangible assets with a defnite useful life price between a willing buyer and seller. Non-quoted Novartis uses cash fow projections for the whole useful investments are subsequently adjusted based on values life of these assets. For goodwill and the Alcon brand derived from using discounted cash fow analysis or name, Novartis generally utilizes cash fow projections other pricing models. These investment values are what for a fve-year period based on management forecasts, is known as “Level 3” in the fair value hierarchy. Probabildebt securities as well as fund investments as availableity-weighted scenarios are typically used. Unrealized gains, except weighted average cost of capital, adjusted for specifc exchange gains related to quoted debt instruments, are country and currency risks associated with cash fow recorded as a fair value adjustment in the consolidated projections to approximate the weighted average cost statement of comprehensive income. Exchange gains related to quoted debt instruments are immediately recognized Im pairm ent of associated com panies in the consolidated income statement under “Other accounted for at equity fnancial income and expense”. A security is assessed for impairment when its marNovartis considers investments in associated compaket value at the balance sheet date is less than initial cost nies for impairment evaluation whenever objective evireduced by any previously recognized impairment. Impairments are mated to be lower than the balance sheet carrying recorded for all other equity securities and other fund amount an impairment charge is recognized for the difinvestments in “Other expense” in the consolidated ference in the consolidated income statement under income statement. Commodities include gold bullion or coins which are valued at the lower of cost or fair value using current market prices. The changes in fair value below cost are Cash and cash equivalents, immediately recorded in “Other fnancial income and m arketable securities, com m odities expense”. Other non-current fnancial assets, including loans and non-current fnancial assets held for long-term strategic purposes, are carried at Cash and cash equivalents include highly liquid investamortized cost, which refects the time value of money ments with original maturities of three months or less, less any allowances for uncollectable amounts. These provisions represent the Options are valued based on a modifed Blackdiference between the trade receivable’s carrying Scholes model using volatility and exercise prices as amount in the consolidated balance sheet and the estimajor observable inputs. Signifcant fnancial difthe Group utilizes derivative fnancial instruments for culties of a customer, such as probability of bankruptcy, the purpose of hedging to reduce the volatility in the fnancial reorganization, default or delinquency in payGroup’s performance due to the exposure of various ments are considered indicators that recovery of the types of business risks. The receivables are recognized in the consolidated income risk reduction is obtained because the derivative’s value statement within “Marketing & Sales” expenses. The overall strategy is aiming to mitLegal and environm ental liabilities igate the currency and interest exposure risk of positions that are contractually agreed and to partially mitigate the Novartis and its subsidiaries are subject to contingenexposure risk of selected anticipated transactions. A prerequisite other product-related litigation, commercial litigation, for obtaining this accounting-hedge relationship is extenand governmental investigations and proceedings. Changes in the fair value of those derivative instruments are recognized immediately in “Other fnancial income Contingent consideration and expense” in the consolidated income statement. In addition, the Group has designated certain longIn a business combination or divestment of a business, term debt components as hedges of the translation risk it is necessary to recognize contingent future payments arising on certain net investments in foreign operations. Usually for on long-term debt designated as net investment hedges Novartis, these are linked to milestone or royalty payof a foreign operation are recognized in other comprements related to certain assets and are recognized as a hensive income and accumulated in currency translation fnancial liability or fnancial asset at their fair value, which efects, to the extent that the hedge is efective. Changes in contingent considInventories eration assets are recognized in “Other income” or “Other expense”, depending on its nature. Inventory is valued at acquisition or production cost the efect of unwinding the discount over time is recdetermined on a frst-in frst-out basis. This value is used ognized for contingent liabilities in “Interest expense” for the “Cost of goods sold” in the consolidated income and for contingent assets in “other fnancial income and statement. Unsalable inventory is fully written of in the expense” in the consolidated income statement. As interest rates embedded in lease arrangeand other post-em ploym ent benefts ments are approximately market rates, revenue under fnance lease arrangements is comparable to revenue the liability in respect of defned beneft pension plans for outright sales. Finance income for arrangements in and other post-employment benefts is the defned benexcess of twelve months is deferred and subsequently eft obligation calculated annually by independent acturecognized based on a pattern that approximates the aries using the projected unit credit method. The current use of the efective interest method and recorded in service cost for such post-employment beneft plans is “Other income”. Operating lease revenue for equipment included in the personnel expenses of the various funcrentals is recognized on a straight-line basis over the tions where the associates are employed, while the net lease term. They are calculated on the basis of historiTreasury shares are initially recorded at fair value on their cal experience and the specifc terms in the individual trade date which is diferent from the settlement date, agreements. Diferences are recorded as a revenue deduction at the time the between the nominal amount and the transaction price related sales are recorded. They are calculated on the on purchases or sales of treasury shares with third parbasis of historical experience and clinical data available ties, or the value of services received for the shares allofor the product, as well as the specifc terms in the indicated to associates as part of share-based compensavidual agreements. In cases where historical experience tion arrangements, are recorded in “Retained earnings” and clinical data are not sufcient for a reliable estimain the consolidated statement of changes in equity. Cash discounts are ofered to customers to encourRevenue recognition age prompt payment and are recorded as revenue deductions. Revenue Following a decrease in the price of a product, we Revenue is recognized on the sale of Novartis Group generally grant customers a “shelf stock adjustment” for products and services and recorded as “Net sales” in their existing inventory for the involved product. Provithe consolidated income statement when there is persions for shelf stock adjustments, which are primarily suasive evidence that a sales arrangement exists; title, relevant within the Sandoz Division, are determined at risks and rewards for the products are transferred to the the time of the price decline or at the point of sale, if the customer; the price is determinable; and collectability is impact of a price decline on the products sold can be reasonably assured. When contracts contain customer reasonably estimated based on the customer’s inventory acceptance provisions, sales are recognized upon the levels of the relevant product. If products are stockWhen there is historical experience of Novartis agreepiled at the request of the customer, revenue is only recing to customer returns and Novartis can reasonably estiognized once the products have been inspected and mate expected future returns, a provision is recorded for accepted by the customer, and there is no right of return estimated sales returns. This is applied to the amounts invoiced, consideration is allocated to the separate elements also considering the amount of returned products to be based on their relative fair values. Revenue is recognized destroyed versus products that can be placed back in once the recognition criteria have been met for each eleinventory for resale. Novartis transfers substantially all the risks and rewards Provisions for revenue deductions are adjusted to incidental to ownership to the customer are treated as actual amounts as rebates, discounts and returns are fnance lease arrangements. The provision represents estimates of the arrangements is recognized at amounts equal to the fair related obligations, requiring the use of judgment when values of the equipment, which approximate the present estimating the efect of these sales deductions. The Group considers that regulatory and other recorded in the consolidated income statement is uncertainties inherent in the development of new prodincluded in the personnel expenses of the various funcucts preclude the capitalization of internal development tions where the associates are employed. The fair internal R&D expenses in the period in which they are value of these grants, after making adjustments for incurred. Such payments are only capitalized if they meet assumptions related to their forfeiture during the vestthe criteria for recognition of an internally generated ing period, is expensed on a straight-line basis over the intangible asset, usually when marketing approval has respective vesting period. The other assets, such as technologies to be used in R&D expense is determined taking into account assumptions activities. If additional payments are made to the origiconcerning performance during the period against tarnator company to continue to perform R&D activities, an gets and expected forfeitures due to plan participants evaluation is made as to the nature of the payments. These assumptions additional payments will be expensed if they are deemed are periodically adjusted. Any change in estimates for to be compensation for subcontracted R&D services not past services is recorded immediately as an expense or resulting in an additional transfer of intellectual property income in the consolidated income statement and rights to Novartis. Such additional payments will be capamounts for future periods are expensed over the italized if they are deemed to be compensation for the remaining vesting period. As a result, at the end of the transfer to Novartis of additional intellectual property vesting period, the total charge during the whole vesting developed at the risk of the originator company. These performance ities that are required by regulatory authorities as a conconditions are based on variables that can be observed dition for obtaining marketing approval are capitalized in the market. If this inventory can be this grant is expensed on a straight-line basis over the subsequently sold, the provision is released to “Other vesting period. Adjustments to the number of equity income” in the consolidated income statement either on instruments granted are only made if a plan participant approval by the appropriate regulatory authority or, does not fulfll the service conditions. They are stated at the lower of carrying amount and fair value less costs of disposal.

Examples include antibiotics for infections managing diabetes through good nutrition , insulin for unstable diabetics diabetes mellitus in dogs prevention , and analgesics for delirium-inducing pain diabetes type 1 update . Diuretics are commonly used medications that are prescribed for the treatment of conditions such as hypertension diabetes 88 , heart failure, and chronic kidney disease. Dehydration may occur in people who do not modify their use of diuretics in hot weather or in other situations where excess water loss occurs. Other medications, such as lithium, may interfere with the kidneys’ regulatory systems, leading to excessive water loss. However, acute water toxicity has been reported from the rapid consumption of large quantities of fluids that greatly exceeded the kidneys’ maximal excretion rate of approximately 0. No adverse intakes have been reported with chronic high intakes of water in health people consuming a normal diet, as long as fluid intake is approximately proportional to losses. Alcohol Alcohol intake appears to Based on limited data, ethanol ingestion did not increase water excretion. Sodium Increased sodium intake Based on limited data, it was not possible to may increase urine volume. Protein Increased protein Studies showed that increased protein intake did consumption may increase not affect water intake or urine volume in water needs. Fiber Fecal water loss is increased Limited studies showed significant increases in with increased dietary fiber. Carbohydrate the presence of dietary On average, 100 g/day of carbohydrates (the amount carbohydrates may affect needed to prevent ketosis) has been shown to decrease body water deficit by decreasing the quantity of body solutes (ketone bodies) that need to be excreted. This response is similar when ketosis occurs with the consumption of very low carbohydrate diets. Excessive water intake can lead to hyponatremia, which is a low concentration of sodium in the blood (defined as serum sodium concentration of less than 135 mmol/L). The lowering of the extracellular fluid sodium concentration causes fluid to move into the intracellular fluid space, resulting in central nervous system edema, lung congestion, and muscle weakness. Hyponatremia can also occur from excessive fluid intake, the underreplacement of sodium, or both, during or after prolonged endurance athletic events. Hyponatremia is rare in healthy persons who consume an average North American diet. The condition is most often seen in infants, psychiatric patients with psychogenic polydipsia (chronic excessive thirst and fluid intake), patients on psychotropic drugs, women who have undergone surgery using a uterine distension medium, and participants in prolonged endurance events, such as military recruits. A series of case studies has suggested that gross overconsumption of fluids (for example, more than 20 L/day) is associated with irreversible bladder lesions and possibly thinner bladder muscles, delayed bladder sensation, and flow rate impairment. It also serves as the medium for transport within the body by supplying nutrients and removing waste. These reference values represent total water intakes that are considered likely to prevent deleterious, primarily acute, effects of dehydration, including metabolic and functional abnormalities. However, on a dayto-day basis, fluid intake, driven by the combination of thirst and mealtime beverage consumption, helps maintain hydration status and total body water at normal levels. This condition leads to central nervous system edema, lung congestion, and muscle weakness. This section is divided into chapters that are organized by nutrient for 35 individual vitamins and minerals. Each chapter provides a table of known nutrient reference values; reviews the function of a given nutrient in the human body; summarizes the known effects of deficiencies and excessive intakes; describes how a nutrient may be related to chronic disease or developmental abnormalities, where data were available; and provides the indicator of adequacy for determining the nutrient requirements. Vitamins covered in Part Three include vitamin A, vitamin B6, vitamin B12, biotin, vitamin C, carotenoids, choline, vitamin D, vitamin E, folate, vitamin K, niacin, pantothenic acid, riboflavin, and thiamin. Minerals covered in Part Three include calcium, chromium, copper, fluoride, iodine, iron, magnesium, manganese, molybdenum, phosphorus, potassium, selenium, sodium chloride, sulfate, and zinc; there is also a chapter on other substances including arsenic, boron, nickel, silicon, and vanadium. The term vitamin A also includes provitamin A carotenoids that are dietary precursors of retinol. The term retinoids refers to retinol and its metabolites, and any synthetic analogues that have a similar structure. The change means that twice the amount of provitamin A–rich carotenoids contained in leafy green vegetables and certain fruits is required to provide a given amount of vitamin A activity. The requirements for vitamin A are based on the assurance of adequate liver stores of vitamin A. Preformed vitamin A (retinol) is naturally found in animal-based foods, whereas dietary carotenoids (provitamin A carotenoids), which are converted to vitamin A in the body, are present in oils, fruits, and vegetables. Common dietary sources of preformed vitamin A in the United States and Canada include liver, dairy products, and fish. Foods fortified with vitamin A are margarine and low-fat and nonfat (skim and partly skimmed) milk. Provitamin A carotenoids are found in carrots, broccoli, squash, peas, spinach, and cantaloupe. The most specific clinical effect of vitamin A deficiency is xerophthalmia and its various stages, including night blindness, conjunctival xerosis, Bitot’s spots, corneal xerosis, corneal ulceration, and scarring. Preformed vitamin A toxicity (hypervitaminosis A) due to high vitamin A intakes may be acute or chronic. Forms of vitamin A include retinol (preformed vitamin A), retinal, retinoic acid, and retinyl esters. Some examples of vitamin A functions include retinal, which is required by the eye to transduce light into the neural signals necessary for vision; retinoic acid, which is required to maintain normal differentiation of the cornea and conjunctival membranes, thus preventing xerophthalmia; and retinioic acid, which is required to regulate the expression of various genes that encode for structural proteins. The term vitamin A also includes provitamin A carotenoids that are the dietary precursors of retinol. The term retinoids refers to retinol and its metabolites, and any synthetic analogues that have a similar structure to retinol. Of the more than 600 forms of carotenoids found in nature, several have provitamin A nutritional activity, but food composition data are available for only three (a-carotene, b-carotene, and b-cryptoxanthin). The efficiency of absorption of preformed vitamin A is generally high, ranging from 70 to 90 percent. Absorption is carrier-mediated and saturable, but becomes nonsaturable at high pharmacological doses. As the amount of ingested preformed vitamin A increases, its absorbability remains high. Efficiency of absorption has been estimated at 9–22 percent, although this decreases as the amount ingested increases. Some carotenoids (b-carotene, acarotene, and b-cryptoxanthin) are converted to vitamin A in the body. Along with exogenous lipids, retinal esters (newly formed in the intestine) and nonhydrolyzed carotenoids are transported from the intestine to the liver in chylomicrons and chylomicron remnants. Retinoic acid, another form of vitamin A, is absorbed via the portal system bound to albumin. Liver, lung, adipose, and other tissues possess carotene enzyme activity, and so it is presumed that carotenes may be converted to vitamin A as they are delivered to tissues. When vitamin A intake is adequate, more than 90 percent of total body vitamin A is located in the liver, which releases the nutrient into the circulation Copyright © National Academy of Sciences. The majority of vitamin A metabolites are excreted in the urine; some vitamin A is also excreted in the bile. Amounts excreted via the bile increase as the liver vitamin A exceeds a critical concentration. Although a large body of observational epidemiological evidence suggests that higher blood concentrations of b-carotenes and other carotenoids obtained from foods are associated with a lower risk of several chronic diseases, there is currently insufficient evidence to support a recommendation that requires a certain percentage of dietary vitamin A to come from provitamin A carotenoids in meeting the vitamin A requirement. For example, consuming the recommended 5 servings of fruits and vegetables per day could provide 5. Special Considerations Vegetarian diets: Preformed vitamin A (retinol) is found only in animal-based foods. People who do not consume such foods must meet their requirements with foods that contain sufficient provitamin A carotenoids, such as deeply colored fruits and vegetables, or with fortified foods, such as margarine, some plant-based beverages, and cereals. Parasites and infection: Malabsorption of vitamin A can occur with diarrhea and intestinal infections, such as those observed in developing countries. With infection and fever, the requirement for vitamin A may be greater than the requirements listed in this chapter, which are based on generally healthy individuals. This change in equivalency values is based on data demonstrating that the vitamin A activity of purified b-carotene in oil is half of the activity of vitamin A. It is also based on recent data demonstrating that the vitamin A activity of dietary b-carotene is one-sixth, rather than one-third, of the vitamin activity of purified b-carotene in oil. This change in bioconversion means that a larger amount of provitamin A carotenoids, and therefore darkly colored, carotenerich fruits and vegetables, is needed to meet the vitamin A requirement.

The manifestations vary and include depressed mood diabetes mellitus 2 , anxiety or worry (or mixture of these) diabetes type 2 mayo clinic , a feeling of inability to diabetic diet honey cope diabetes insipidus excessive thirst , plan ahead, or continue in the present situation, as well as some degree of disability in the performance of daily routine. These disorders have previously been classified as various types of "conversion hysteria". The symptoms may develop in close relationship to psychological stress, and often appear suddenly. The diagnosis should not be made in the presence of organic brain disorders, intoxication, or excessive fatigue. If any physical disorders are present, they do not explain the nature and extent of the symptoms or the distress and preoccupation of the patient. Includes: Body dysmorphic disorder Dysmorphophobia (nondelusional) Hypochondriacal neurosis Hypochondriasis Nosophobia Excludes: delusional dysmorphophobia (F22. In one type, the main feature is a complaint of increased fatigue after mental effort, often associated with some decrease in occupational performance or coping efficiency in daily tasks. In both types a variety of other unpleasant physical feelings is common, such as dizziness, tension headaches, and feelings of general instability. Worry about decreasing mental and bodily well-being, irritability, anhedonia, and varying minor degrees of both depression and anxiety are all common. This diagnosis should not be made in the presence of known physical disorders associated with weight loss. There is often, but not always, a history of an earlier episode of anorexia nervosa, the interval ranging from a few months to several years. Generally, if the sleep disorder is one of the major complaints and is perceived as a condition in itself, the present code should be used along with other pertinent diagnoses describing the psychopathology and pathophysiology involved in a given case. Includes: Psychogenic inversion of: • circadian rhythm • nyctohemeral rhythm • sleep rhythm Excludes: disorders of the sleep-wake schedule (organic) (G47. Recall of the event, if any, is very limited (usually to one or two fragmentary mental images). Quite often there is a recurrence of the same or similar frightening nightmare themes. Any resulting mental disturbances are usually mild, and often prolonged (such as worry, emotional conflict, apprehension) and do not of themselves justify the use of any of the categories in this chapter. Attempts to dissuade or forbid the use of the substance are often met with resistance; for laxatives and analgesis this may be in spite of warnings about (or even the development of) physical harm such as renal dysfunction or electrolyte disturbances. Some of these conditions and patterns of behaviour emerge early in the course of individual development, as a result of both constitutional factors and social experience, while others are acquired later in life. They represent extreme or significant deviations from the way in which the average individual in a given culture perceives, thinks, feels and, particularly, relates to others. F60 Specific personality disorders Note: these are severe disturbances in the personality and behavioural tendencies of the individual; not directly resulting from disease, damage, or other insult to the brain, or from another psychiatric disorder; usually involving several areas of the personality; nearly always associated with considerable personal distress and social disruption; and usually manifest since childhood or adolescence and continuing throughout adulthood. There may be excessive self-importance, and there is often excessive selfreference. Includes: Personality (disorder): • amoral • antisocial • asocial • psychopathic • sociopathic Excludes: conduct disorders (F91. There is a liability to outbursts of emotion and an incapacity to control the behavioural explosions. The change cannot be explained by a previous personality disorder and should be differentiated from residual schizophrenia and other states of incomplete recovery from an antecedent mental disorder. In some cases they simply serve to enhance sexual excitement achieved in ordinary ways. There is usually, but not invariably, sexual excitement at the time of the exposure and the act is commonly followed by masturbation. If the subject prefers to be the recipient of such stimulation this is called masochism; if the provider, sadism. Likely to result in marked developmental delays in childhood but most can learn to develop some degree of independence in self-care and acquire adequate communication and academic skills. Usually, the delay or impairment has been present from as early as it could be detected reliably and will diminish progressively as the child grows older, although milder deficits often remain in adult life. This is not simply a consequence of a lack of opportunity to learn, it is not solely a result of mental retardation, and it is not due to any form of acquired brain trauma or disease. The deficit concerns mastery of basic computational skills of addition, subtraction, multiplication, and division rather than of the more abstract mathematical skills involved in algebra, trigonometry, geometry, or calculus. Includes: Atypical childhood psychosis Mental retardation with autistic features Use additional code (F70-F79) to identify mental retardation. This syndrome is also often associated with a variety of developmental delays, either specific or global. Caution should be employed before using this category, especially with older children, because clinically significant conduct disorder will usually be accompanied by dissocial or aggressive behaviour that goes beyond mere defiance, disobedience, or disruptiveness. Common simple motor tics include only eye-blinking, neck-jerking, shouldershrugging, and facial grimacing. The condition may represent an abnormal continuation of normal infantile incontinence, it may involve a loss of continence following the acquisition of bowel control, or it may involve the deliberate deposition of faeces in inappropriate places in spite of normal physiological bowel control. Includes: Functional encopresis Incontinence of faeces of nonorganic origin Psychogenic encopresis Use additional code to identify the cause of any coexisting constipation. Stereotyped selfinjurious behaviour includes repetitive head-banging, face-slapping, eye-poking, and biting of hands, lips or other body parts. For use of this category reference should be made to the relevant morbidity and mortality coding rules and guidelines. Use additional code from (I11) (hypertensive heart disease) or (I13) (hypertensive heart and renal disease) for heart failure due to hypertension Excludes: complicating: • abortion or ectopic or molar pregnancy (O00-O07) (O08. Includes: Decubitus [pressure] ulcer limited to erythema [redness] only, without skin breakdown L89. Use additional codes to identify any associated hypertensive renal disease (I12) or hypertensive heart and renal disease (I13). For use of this category reference should be made to the morbidity coding rules and guidelines. Includes: the listed conditions, without further specification, as the cause of mortality, morbidity or additional care, in newborn Excludes: low birth weight due to slow fetal growth and fetal malnutrition (P05. Usually implies a birth weight>90th percentile for gestational age or 4000g or more at term Excludes: birth weight of 4500g or more (P08. Where multiple sites of injury are specified in the titles, the word "with" indicates involvement of both sites, and the word "and" indicates involvement of either or both sites. Combination categories for multiple injuries is provided for use when there are insufficient detail as to the nature of the individual conditions, or for primary tabulation purposes when it is more convenient to record single code; otherwise, the component injuries should be coded separately. S84 Injury of nerves at lower leg level Excludes: injury of nerves at ankle and foot level (S94. Includes: • bicycle • tricycle Excludes: motorized bicycle see definition (k) (j) A pedal cyclist is any person riding on a pedal cycle or in a sidecar or trailer attached to such a vehicle. Includes: • motor-driven tricycle • motorized rickshaw • three-wheeled motor car Excludes: • all-terrain vehicle see definition (x) • motorcycle with sidecar see definition (k) (n) A car [automobile] is a four-wheeled motor vehicle designed primarily for carrying up to 10 persons. Includes battery-powered: • airport passenger vehicle • coal-car in mine • forklift (truck) • logging car • self-propelled truck, industrial • station baggage truck (powered) • tram, truck or tub (powered) in mine or quarry • truck (baggage) (mail) (v) A special vehicle mainly used in agriculture is a motor vehicle designed specifically for use in farming and agriculture (horticulture), for example to work the land, tend and harvest crops and transport materials on the farm. Includes combine harvester: • self-propelled farm machinery • tractor (and trailer) (w) A special construction vehicle is a motor vehicle designed specifically for use in the construction (and demolition) of roads, buildings and other structures. Instead, code to the appropriate categories V87-V88, V90-V94, V95V97, taking into account the order of precedence given in note 2 above. Excludes: bites, venomous (X20-X29) stings (venomous) (X20-X29) W50 Hit, struck, kicked, twisted, bitten or scratched by another person Excludes: assault (X85-Y09) struck by objects (W20-W22) W51 Striking against or bumped into by another person Excludes: fall due to collision of pedestrian (conveyance) with another pedestrian (conveyance) (W03. Evidence of alcohol involvement in combination with substances specified below may be identified by using the supplementary codes Y90-Y91. It includes self-inflicted injuries, but not poisoning, when not specified whether accidental or with intent to harm (X40-X49) Follow legal rulings when available. For example, nephroblastoma (8960/3), by definition, always arises in the kidney; hepatocellular carcinoma (8170/3) is always primary in the liver; and basal cell carcinoma (8090/3) usually arises in the skin. However, if the term "Infiltrating duct carcinoma" is used for a primary carcinoma arising in the pancreas, the correct code would be C25. These codes are provided for use as supplementary or additional codes to identify the resistance of a condition to antimicrobial drugs.

Evidence of sinus disease must be carefully evaluated by a specialist because of the risk of sudden and severe incapacitation from barotrauma diabetes mellitus type 2 exercise . Any applicant seeking certification for the first time with a functioning tracheostomy diabetes diet weekly menu , following laryngectomy diabetes eyesight , or who uses an artificial voice-producing device should be denied or deferred and carefully assessed diabetic diet usda . Some conditions may have several possible causes or exhibit multiple symptomatology. Other — clarity, discharge, dryness, ptosis, protosis, spasm (tic), tropion, or ulcer. Cornea — observe for abrasions, calcium deposits, contact lenses, dystrophy, keratoconus, pterygium, scars, or ulceration. Size, shape, and reaction to light should be evaluated during the ophthalmoscopic examination. Retina and choroid — examine for evidence of coloboma, choroiditis, detachment of the retina, diabetic retinopathy, retinitis, retinitis pigmentosa, retinal tumor, macular or other degeneration, toxoplasmosis, etc. End point nystagmus is a physiologic nystagmus and is not considered to be significant. An applicant will be considered monocular when there is only one eye or when the best corrected distant visual acuity in the poorer eye is no better than 20/200. It takes time for the monocular airman to develop the techniques to interpret the monocular cues that substitute for stereopsis; such as, the interposition of objects, convergence, geometrical perspective, distribution of light and shade, size of known objects, aerial perspective, and motion parallax. In addition, it takes time for the monocular airman to compensate for his or her decrease in effective visual field. A monocular airman’s reduced effective visual field would be reduced even further than 42 degrees by speed smear. Applicants who have had monovision secondary to refractive surgery may be certificated, providing they have corrective vision available that would provide binocular vision in accordance with the vision standards, while exercising the privileges of the certificate. The use of contact lens(es) for monovision correction is not allowed: fi the use of a contact lens in one eye for near vision and in the other eye for distant vision is not acceptable (for example: pilots with myopia plus presbyopia). Additionally, designer contact lenses that introduce color (tinted lenses), restrict the field of vision, or significantly diminish transmitted light are not allowed. Please note: the use of binocular contact lenses for distance-correction-only is acceptable. It is used as an alternative to eyeglasses, refractive surgery, or for those who prefer not to wear contact lenses while awake. There is no reasonable or reliable way to determine standards for the entire period the lenses are removed. The Examiner should deny or defer issuance of a medical certificate to an applicant if there is a loss of visual fields or a significant change in visual acuity. Secondary glaucoma is often unilateral, and if the cause or disease process is no longer active and the other eye remains normal, certification is likely. Individuals who have had filter surgery for their glaucoma, or combined glaucoma/cataract surgery, can be 56 Guide for Aviation Medical Examiners considered when stable and without complications. Miotics such as pilocarpine cause pupillary constriction and could conceivably interfere with night vision. Sunglasses are not acceptable as the only means of correction to meet visual standards, but may be used for backup purposes if they provide the necessary correction. Mention should be made that sunglasses do not protect the eyes from the effects of ultra violet radiation without special glass or coatings and that photosensitive lenses are unsuitable for aviation purposes because they respond to changes in light intensity too slowly. Examples include retinal detachment with surgical correction, open angle glaucoma under adequate control with medication, and narrow angle glaucoma following surgical correction. The Examiner may not issue a certificate under such circumstances for the initial application, except in the case of applicants following cataract surgery. The Examiner may issue a certificate after cataract surgery for applicants who have undergone cataract surgery with or without lens(es) implant. Lungs and chest (Not including breast examination) 1 Nystagmus of recent onset is cause to deny or defer certificate issuance. If nystagmus has been present for a number of years and has not recently worsened, it is usually necessary to consider only the impact that the nystagmus has upon visual acuity. The Examiner should be aware of how nystagmus may be aggravated by the forces of acceleration commonly encountered in aviation and by poor illumination. For example, if the medication half-life is 6-8 hours, wait 40 hours (5x8) after the last dose to fly. Examiner must caution airman not to fly until course of oral steroids is completed and airman is symptom free. If the applicant has frequent exacerbations or any degree of exertional dyspnea, certification should be deferred. A person who has such a history is usually able to resume airmen duties 3 months after the surgery. High G-forces of aerobatics or agricultural flying may stress both systems considerably. The medical standards do not specify pulse rates that, per se, are disqualifying for medical certification. Bradycardia of less than 50 beats per minute, any episode of tachycardia during the course of the examination, and any other irregularities of pulse other than an occasional ectopic beat or sinus arrhythmia must be noted and reported. Temporary stresses or fever may, at times, result in abnormal results from these tests. If the Examiner believes this to be the case, the applicant should be given a few days to recover and then be retested. If this is not possible, the Examiner should defer issuance, pending further evaluation. Check for resonance, asthmatic wheezing, ronchi, rales, cavernous breathing of emphysema, pulmonary or pericardial friction rubs, quality of the heart sounds, murmurs, heart rate, and rhythm. It should be noted whether it is functional or organic and if a special examination is needed. It is recommended that the Examiner conduct the auscultation of the heart with the applicant both in a sitting and in a recumbent position. Aside from murmur, irregular rhythm, and enlargement, the Examiner should be careful to observe for specific signs that are pathognomonic for specific disease entities or for serious generalized heart disease. Particular reference should be given to cardiovascular abnormalities cerebral, visceral, and/or peripheral. A statement must be included as to whether medications are currently or have been recently used, and if so, the type, purpose, dosage, duration of use, and other pertinent details must be provided. A statement of the ages and health status of parents and siblings is required; if deceased, cause and age at death should be included. Also, any indication of whether any near blood relative has had a “heart attack,” hypertension, diabetes, or known disorder of lipid metabolism must be provided. Smoking, drinking, and recreational habits of the applicant are pertinent as well as whether a program of physical fitness is being maintained. The presence of an aneurysm or obstruction of a major vessel of the body is disqualifying for medical certification of any class. The presence of permanent cardiac pacemakers and artificial heart valves is also disqualifying for certification. Describe the clinical history since the last evaluation: 2. Applicants for firstor secondclass must provide this information annually; applicants for third-class must provide the information with each required exam. The maximum systolic during exam is 155mmHg and the maximum diastolic is 95mmHg during the exam. If the airman’s blood pressure is elevated in clinic, you have any the following options: fi Recheck the blood pressure. Can I hold an exam longer than 14 days to allow the airman time provide the necessary informationfi The airman had medication(s) adjusted and now meets the standards, but it took longer than 14 days and the exam was deferred. Cardiac enlargement or other evidence of cardiovascular abnormality, If the applicant wishes further consideration, a consultation is required, preferably from the applicant’s treating physician. A 1month observation period must elapse after the procedure before consideration for certification. If the Examiner is in doubt, it is usually better to defer issuance rather than to deny certification for such a history. Check the hematopoietic and vascular system by observing for pallor, edema, varicosities, stasis ulcers, venous distention, nail beds for capillary pulsation, and color. Observation: the Examiner should note any unusual shape or contour, skin color, moisture, temperature, and presence of scars.

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