Precose

Angela L. Turpin, MD

• Associate Medical Director of Diabetes Program
• Assistant Professor of Pediatrics
• University of Missouri?ansas City School of Medicine
• Children? Mercy Hospitals & Clinics
• Kansas City, Missouri

The uninsured face considerable difficulty in obtaining even routine care diabetic diet quantity precose 50 mg lowest price, as well as the prospect of financial ruin in the event of a medical emergency diabete facts order cheap precose line. Nevertheless definition of diabetes type 2 purchase precose 25mg amex, the lack of a coordinated national coverage system does not mean that the government is absent from the health insur ance market ketotic diabetic dogs buy precose 25mg online. In fact diabetes symptoms joints discount precose, the government directly funds coverage for al most 30% of the population and indirectly funds coverage for another com/portal/site/imshealth/menuitem diabetic pumpkin pie order 50 mg precose free shipping. The appropriate accounting for pharmaceutical profitability is somewhat controversial. Some analysts believe that the treatment of research and development costs in standard assessments is incorrect, contending that it should be treated as an investment subject to depreciation rather than as an expense. Nevertheless, the resulting profitability is still consistently higher than the average for all American industries. However, the government shapes, oversees, and in directly funds the private market for employerprovided coverage, the mainstay for the remainder of the country. Private health insurance in its present form would not exist in the United States were it not for a sustained government role that started around the middle of the twentieth century and has steadily grown ever since. The Creation of Private EmployerBased Coverage the first general private health insurance plans were created dur 216 ing the early years of the Great Depression. Baylor Uni versity Hospital in Houston launched the first one in 1929, offering a group of schoolteachers up to twentyone days of hospital care each 218 year for six dollars per person. In the early 1930s, plans were developed in 219 California and New Jersey to provide care at multiple institutions. In 1939, a similar concept was applied to physician 222 services for lowincome families in California. Employmentbased insurance, supported by a tax subsidy, covered over 155 million people. In particular, they could not raise and maintain the same level of financial reserves that state regulators generally re 225 quired to guarantee the ability to pay claims. New York was the first state to address this imbalance in 1934, when it enacted an enabling statute that conferred special regulatory status on the new health in 226 surance mechanisms. Under this legislation, if Blue Cross plans agreed to maintain their nonprofit status and remain under the con trol of member hospitals, they would be exempted from the reserve 227 requirements that applied to the rest of the insurance industry. Through this regulatory leniency, state governments had enabled the first health insurance plans to take shape. With their structure in place, the major catalyst for their widespread expansion arose about ten years later through the intersession of another government regu latory action. The legislation was based on the reasoning that the new plans did not need the same level of financial backing because they could honor claims by providing ser vices directly. To ease the regulatory burden on these new entities in order to encourage their growth, many states passed enabling statutes to exempt them from some provisions of their insurance codes. In 1943, to accommodate the needs of employers having difficulty at tracting workers, the War Labor Board exempted fringe benefits, such as health insurance, from the definition of wages, thereby permitting 232 employers to add such compensation without violating the freeze. Enrollment in Blue Cross plans, which were widely offered through employment as a result of this ruling, increased almost fourfold dur 233 ing the War from seven to twentysix million. This regulatory action led to an even more influential government step in the postwar years. In keeping with this reasoning, the Internal Revenue Service took the po 235 sition that these sums were not subject to income tax. In 1954, as part of a comprehensive overhaul of the Internal Revenue Code, Con 236 gress ratified this position in legislation. While employmentbased health insurance enjoyed this substantial financial boost, coverage that individuals obtained directly from insur ance companies did not. Amounts received as benefits paid out by employersponsored health insurance plans had been considered taxexempt since the income tax was first instituted, and this policy was also continued in the 1954 revision. Policies sold directly to individuals have come to represent a 239 tiny portion of the market, in the range of about six percent. The amounts government coffers forgo by exempting employerpaid health insurance from taxation represent a subsidy for those able to take advantage of this form of insurance. By exempting employerpaid health insurance premiums from income tax, federal 241 and state governments lost a total of over $200 billion in 2006. This means that the tax subsidy for private insurance is the third most expensive government health care financing program, behind Medicare and 243 Medicaid. It represents over onethird of the aggregate amount 244 Americans pay for private employersponsored coverage each year. The magnitude of government financial support for private health insurance means that this product is not offered through a truly pri vate mechanism. Rather, the government heavily shapes and funds 237 the premiums for individual insurance policies are tax deductible to the extent that, when combined with other medical expenses, they exceed 7. The tax sub sidy for private employersponsored health insurance was valued at approximately $240 billion in 2010, making it the thirdmost expensive. By indirectly paying Americans almost $250 billion a year to obtain health coverage at work, the pub licprivate partnership that began with special regulatory treatment for the first Blue Cross plans has promoted an employerbased system that rests on coverage through private firms. This includes statutes that limit unfair insurance practices and case law that permits aggrieved beneficiaries to sue insurance companies 247 for damages in state courts. In these selffunded plans, the employer pays claims directly, rather than purchasing coverage for its workers. Policies sold directly to the public must comply with more rigorous state regula tory oversight, and the companies that sell them are more vulnerable to 251 lawsuits for their administration of coverage. Without the tax subsidy and regulatory leniency, health care cover age would almost certainly be provided directly to individuals to a much greater extent than it is currently. Moreover, absent this support from the government, most people would likely purchase less coverage 253 than they presently do. There would consequently be a smaller pool of money available for reimbursing providers, causing reimbursement rates to fall. The Creation of Managed Care In addition to structuring and funding private health insurance, the government created an important subindustry within private health insurance. The concept origi nated in the late 1960s in a proposal by Paul Elwood, a Minneapolis family physician, based on the model of what were then known as 255 prepaid plans. Elwood saw in these plans a way to finance the full range of 257 care while keeping a tight rein on costs. By directly employing phy sicians and owning or managing the facilities in which they worked, 258 prepaid plans had strong tools with which to control costs. Its success led to the spinoff of the health plan after the War into an independent nonprofit organization open to employees of other companies. After the War, the City of New York opened the Health Insurance Plan to cover municipal workers. Similar plans based on a clinic model founded during this time included the Group Health Insurance Plan in Washington, D. They paid physicians a salary that remained largely fixed regardless of the num ber of services they provided or procedures they performed. This eliminated the fi nancial incentive to overtreat, since treatment no longer necessarily generated addi tional payments. The concept appealed to the Nixon Administration, which was re 260 ceptive to a marketbased approach to health reform. It also implemented a regulato ry structure that determined the shape of this new segment of the in dustry. Under this mechanism, a physician is responsible for a panel of patients who can see her as of ten as necessary. In return, the physician is paid a set monthly fee for each patient, regardless of how often the physician actually sees the patient or the number of services actually provided. All patients must see their designated primary care physician first for any ailment and receive a referral from her before consulting a specialist. Proce dures and tests specialists perform or order are reviewed for necessity before payment is authorized. Hospitalizations must be preapproved, and the maximum length of stay that is eligible for payment is determined in advance. This structure represents an attempt to coordinate care to control costs and improve quality with dispersed networks of providers, rather than centralized clinics. However, building on this solid start, a set of additional gov ernment programs implemented over the next twenty years gave ma naged care added momentum. It substantially limited the scope of state regulatory oversight for managed care plans that were offered 265 through employers. The experience was considered favorable, and by the end of the 1990s, most states were using managed care for a substantial portion 268 of their Medicaid populations. With this model in mind, the Medi care program began to experiment with managed care at about the 269 same time. After promising initial trials, managed care arrange ments were formally integrated into the program as a beneficiary op tion under the Balanced Budget Act of 1997 as a new Part C of the 270 Medicare program. Opening these two huge public markets enabled many managed care organizations to significantly expand their scope of operations. The horizons of established companies expanded well beyond their 272 original expectations. Many smaller companies sprang up through out the country, often to be acquired by larger ones seeking to meet 273 the growing market demand. What had been a largely local industry in the 1970s expanded to include many national players, growing 274 through mergers, consolidations, and acquisitions. With these changes, employers could select from a range of insurance products to offer their workers with different levels of re striction and corresponding variations in premiums, all under the pa 276 radigm of integrating the financing with the provision of health care. The growth of managed care since the government first catalyzed the market has been tremendous. This number grew to seventytwo plans by 1973, and 278 almost doubled to 142 in 1974, the year after the Act was passed. Enrollment grew from six million to over 281 twentynine million subscribers between 1976 and 1987. Today, managed care is the dominant form of health insurance coverage in the United States. During the 1990s, as large, national managed care companies swal lowed smaller local ones, their bargaining clout drove down fees paid 287 to hospitals and physicians in many markets. This, in turn, led many providers to consolidate into health systems, hospital chains, and large 288 physiciangroup practices to try to gain a better negotiating position. By the end of the 1990s, much of American health care had become a 289 more centralized enterprise. GovernmentCreated Health Care and the Larger Economy these examples of governmentcreated health care industry sec tors are by no means exhaustive. In creating American health care as it exists today, the govern ment established not just a vibrant industry but a pillar of the larger economy. Several major cities rely on health care as a critical economic pillar, including Boston, 294 Philadelphia, San Francisco, and Nashville. Cities such as these, and 290 From 1980 to 2006, the number of home health agencies increased from 2924 to 8618, outpatient physical therapy providers from 419 to 3009, and portable xray providers from 216 to 549. Between 1985 and 2004, the number of ambulatory surgery centers certified to provide services under Medicare grew from 336 to 4136, of home health agencies from 5679 to 7519, of outpatient physical therapy providers from 854 to 2971, of port able xray services from 308 to 608, and of hospice providers from 164 to 2645. With out health care, national employment during this time would have 298 contracted. They did this by financing health care services, both directly through Medicare, Medicaid, and other programs, and indi rectly through taxsubsidized private health insurance and by increas ing the supply of providers through programs that funded hospital expansion and physician training. In each case, government involve ment brought about dramatic growth in the private sector, including the creation and maintenance of new industry segments. The ramifications of this step for the private health care in dustry are likely to follow the same path as prior programs.

She has been year of followup diabetes symptoms body odor order precose mastercard, 25% in the acyclovir group and without the ring for 3 days because she did not have 20% in the valacyclovir group experience a recur a new one with her for replacement diabetes early pregnancy signs buy generic precose canada. She is many patients (in 1 year) would need to be treated worried about becoming pregnant diabetes biochemic medicines generic 50 mg precose otc. Which is the with valacyclovir over acyclovir to prevent one best recommendation for T managing diabetes 85 buy 50mg precose with mastercard. Azithromycin 500 mg intravenously or orally tive because she is beyond the 72hour time daily for 6 weeks diabetes test online free precose 25 mg overnight delivery. He is taken to the emergency department by ambulance after experiencing paralysis on the right side of his body diabetes insipidus organization order genuine precose line. In the emergency department, a laboratory profle was performed, which was positive for the Venereal Disease Research Laboratory test (syphilis test) with 10 white blood cells/mm3. Penicillin G 4 million units every 4 hours intravenously for 14 days after penicillin desensitization. Domain I: PatientCentered Pharmacotherapy, Tasks 11, 12, 15, 16, 17, 18, 110, 111, 112, 113, 114, 115, 117, 21, 34, 41, 42, 43, 45, 46, 52, 53 2. Defnition: Cessation of menstrual periods for 1 year, also known as fnal menstrual period, loss of ovarian follicular function 2. May cause increased skin temperature, nausea, dizziness, headache, palpitations, diaphoresis, and night sweats b. Decrease in estrogen causes thinning of hair of the mons and shrinkage of the labia minora; atrophy of vulva leads to pruritus and pain. Thinning of urethra and bladder lining and decreased muscle tone result in recurrent episodes of urinary frequency and urgency with dysuria. Primary indications in menopause: Treatment of moderate to severe menopause symptoms, treat ment of moderate to severe vulvar and vaginal atrophy due to menopause, and prevention of post menopausal osteoporosis b. Benefts of estrogen (a) Relieves genitourinary atrophy (if only symptom, may use estrogen vaginal product locally) (b) Relieves vasomotor instability (c) Osteoporosis: Reduction in hip fractures by 25%; reduction in vertebral fractures by 50%. Randomized trial of estro gen plus progestin for secondary prevention of coronary heart disease in postmeno pausal women. Risks of estrogen (a) Endometrial cancer: Risk increases with unopposed estrogen use in women with an intact uterus. Effects of conjugated equine estrogens on breast cancer and mammography screening in postmenopausal women with hysterectomy. Benefts of progestogen (progestogen umbrella term for progesterone [natural] and progestins [synthetic]) Decreased risk of estrogeninduced irregular bleeding, endometrial hyperplasia, and carcinoma iv. Randomized trial of estrogen plus progestin for sec ondary prevention of coronary heart disease in postmenopausal women. Other fndings related to cardiovascular outcomes from various trials (a) Venous thromboembolism (1) Observational studies indicated increased risk. Controversy exists because the average age of women was older; thus, increases in breast cancer or cardiovascular disease could be caused by age (Table 1). Further information suggests increased risk of ovarian cancer (considered rare, data confict ing); longterm use greater than 5 years may increase risk, particularly in estrogenonly ther apy; overall risk of occurrence considered rare. In general, topical treatment is suff cient and should be tried before oral preparations for patients experiencing no other symptoms. Check after 3 months to 1 year and attempt to discontinue if asymptomatic; if symptoms recur, treat for an additional 3 months; best to limit treatment to less than 5 years ii. Unopposed estrogen (a) Women with a uterus must have a progestogen and cannot use estrogen alone; use of estro gen alone in women with a uterus increases the risk of endometrial cancer. Original reference: Effects of hormone replacement therapy on endometrial histology in postmenopausal women. In general, topical treatment is suffcient and should be tried before oral preparations for patients experiencing no other symptoms. Estrogen plus continuous progestogen (a) Continuous estrogen daily (b) Continuous progestogen 1. Intermittent (a) Continuous estrogen daily (b) Three days on progestogen, 3 days off (c) Seldom used f. Evaluation of vaginal bleeding (a) Unopposed estrogen: Any episode of vaginal bleeding unless the woman has had a health assessment deemed normal in the past 6 months (b) Estrogen plus cyclic progestogen: If bleeding occurs other than at the time of expected withdrawal bleeding (c) Estrogen plus continuous progestogen: If bleeding is heavier than normal, is prolonged (longer than 10 days at a time), is frequent (more often than monthly), or persists for more than 10 months after beginning therapy g. Oral Estrogen Products Brand Name Generic Name Strengths (mg) Enjuvia Synthetic conjugated estrogens, B 0. Transdermal Estrogen Products Brand Formulation Estrogen Provided Dose Unique Traits and Name (mg/day) Counseling Points Alora 17Estradiol 0. Combination Products Brand Name Generic Name Hormone Strengths Dose Activella, Mimvey, 17Estradiol/ 0. Indicated for the treatment of moderate to severe dyspareunia caused by vulvar and vaginal atrophy due to menopause ii. Agonist on endometrial lining, affects uterine endometrium; it is recommended that women with a uterus add a progestin to any agent with estrogenic properties, although clinical studies with ospemifene alone did not fnd an increased risk of endometrial hyperplasia. Adverse reactions (greater than 1%) (a)Hotfashes (b) Muscle cramps (c) Vaginal discharge (d) Hyperhidrosis iv. Drug interactions (a) Rifampin decreases ospemifene exposure by 59%, and they should not be used together. Indicated for treatment of moderate to severe vasomotor symptoms, prevention of osteoporosis ii. Common adverse effects: Muscle spasms; nausea and vomiting; throat, neck, or upper abdom inal pain; and indigestion 4. Bioidentical hormones: May still have adverse effects similar to those of conjugated estrogens b. Androgens: Testosterone may help with sexual dysfunction but not vasomotor symptoms; not approved for use d. Phytoestrogens (see below for soy isofavones): Act similarly to estrogen and carry similar contraindications. Soy isofavones: May still have adverse effects similar to those of conjugated estrogens b. Black cohosh: Some effectiveness for vasomotor symptoms; reports of liver toxicity 7. She has tried exercise, diet, and antide pressants to help relieve her hot fashes but has been unsuccessful. The interval may be longer in patients with Tscores in the normal or upper bone mass range who do not have major risk factors. Alendronate (Fosamax, Binosto, Fosamax Plus D), risedronate (Actonel, Atelvia), ibandronate (Boniva), zoledronic acid (Reclast) b. Laboratory values: Decreases in serum calcium concentrations; decreases in serum phosphorus concentrations in the frst month iv. Highdose intravenous administration (usually for can cerrelated issues) has a greater risk than oral therapy. Drug holidays are controversial; bone density may decrease 5 years after discontinuation of bisphosphonate therapy, but risk of hip fracture stays the same; however, higher risk of vertebral fracture may occur. Atrial fbrillation: Possible increased risk of atrial fbrillation but not of stroke or cardiovascular mortality (Sharma A, Chatterjee S, ArbabZadeh A, et al. Risk of serious atrial fbrillation and stroke with use of bisphosphonates: evidence from a metaanalysis. Drugfood interactions: Wait at least 30 minutes after taking bisphosphonate before taking any medications, food, or drinks except for water. Alendronate with vitamin D: 70 mg/week with 2800 international units of vitamin D3 or 70 mg/week with 5600 international units of vitamin D3 iii. Alendronate 70mg effervescent tablet/week (Binosto): Dissolve tablet in 4 oz water, wait for about 5 minutes for effervescence to stop, stir for 10 seconds, and drink contents. Has similar recommendations of waiting 30 minutes before eating or drinking and staying upright for at 30 minutes after administration iv. Zoledronic acid: 5 mg intravenously annually for treatment and every 2 years for prevention (infuse over a minimum of 15 minutes); reduces nonvertebral fracture risk by 25%, hip frac ture by 40%, and vertebral fracture risk by 70%. Shown to decrease mortality in highrisk patients who have suffered a hip fracture (only bisphosphonate shown to decrease mortality) h. Recommended for all patients with osteoporosis to maintain normal calcium concentrations and to prevent hypocalcemia associated with other drug treatments for osteoporosis b. Higher doses may increase risk of constipation, contribute to kidney stones, and inhibit absorption of zinc or iron (Table 8). Most common forms: Calcium carbonate (take with food), calcium citrate (take with or without food, may be good option for patients taking antacids or acidsuppressive therapy or for patients with achlorhydria) Table 8. Higher doses of vitamin D may be necessary for those with vitamin D levels less than 30 ng/mL. Mechanism: Selective estrogen receptor modulator (a) Reduction in resorption of bone (b) Decrease in overall bone turnover (c) Data suggest estrogen antagonist in uterine and breast tissue. Adverse reactions (5% or more) (a)Hotfashes (b) Muscle cramps (c) Throat, neck, and muscle pain (d) Dizziness (e) Nausea and vomiting v. Indicated for treatment of osteoporosis in women who are more than 5 years postmenopause c. Not a frstline drug; useful for bone pain caused by vertebral compression fractures d. Effcacy: Nasal calcitonin reduces the incidence of new vertebral fractures by 36%. Recombinant human parathyroid hormone regulates bone metabolism, intestinal calcium absorp tion, and renal tubular calcium and phosphate reabsorption. Decreases vertebral fractures by 65% and nonvertebral fractures by 53%; not shown to decrease hip fractures c. Drug interactions: Increases calcium concentrations and may increase risk of digoxin toxicity g. Denosumab (Prolia): Approved for postmenopausal women with osteoporosis and for men and women with bone loss associated with prostate or breast cancer a. Hypocalcemia: Patients should take calcium and vitamin D together with denosumab; those with impaired renal function are more likely to have hypocalcemia. Limiting alcohol intake: Affects fall risk, 2 or more units of alcohol per day associated with 20% of falls at home, according to one study. She takes calcium 1200 mg orally per day in divided doses and vitamin D 600 international units/day orally. No further treatment is needed; continue calcium 1200 mg/vitamin D 600 international units/day orally. Teriparatide 20 mcg subcutaneously daily and continue calcium 1200 mg/vitamin D 600 international units/day orally. Miacalcin nasal spray 1 spray (200 international units) in one nostril daily; continue calcium 1200 mg/ day orally, and increase vitamin D to 800 international units/day orally. Risedronate 35 mg orally every week; continue calcium 1200 mg orally per day, and increase vitamin D to 800 international units/day orally. Teratogen: Drug or environmental agent with the potential to cause abnormal fetal growth and development 2. Teratogenicity: Capability of producing congenital abnormalities, major or minor malformations B. Metabolic activity of the placenta; excretion of medications by the fetus occurs in liver and placenta D. B: Animal studies indicate no risk, or animal studies show a risk that has not been shown in human studies. New labeling has taken place for new products approved after June 30, 2015; older products will be phased in over the next few years. Factors to Consider When Initiating Medications in Pregnant Women (Tables 10, 11, 12, and 13) 1. Drugs Commonly Used in Pregnancy (if beneft outweighs risk) Acetaminophen Cetirizine Erythromycin Cephalosporins Penicillin Table 12.

While each service has its own specific procedures and rules for granting delays diabetes mellitus ketones buy generic precose on line, deferments blood glucose 90 cheap precose master card, exemptions diabetic diet beans order discount precose, and separations blood glucose biosensor generic precose 25mg on-line, they generally follow a similar template diabetes mellitus video lecture buy discount precose 25mg line. Under these general guidelines gestational diabetes signs buy generic precose 25mg on-line, the ability of any servicemember to receive a delay, deferment, exemption, or separation is left to the discretion of the commanding officer of the callup unit. Therefore, it is important that ser vicemembers seeking any modification to their mobilization orders are knowledgeable of the rules and their rights. If you feel you have been wronged by the military and are unable to get your issue resolved with the command, there are additional steps you should take, including filing a complaint with the appropriate inspector general or equal opportunity office, contacting nonprofit, nongovernmental organizations that provide information to military mem bers, and consulting various other resources including veterans advocacy groups, military legal assistance officers, and, in some instances, your member of Congress or a private attorney. Delays are usually authorized for two months and are rarely given for longer than four months beyond the initial report date. The military grants delays in several situations including those where the ser vicemember: a. Examples include: the death or severe illness of a spouse, leaving the servicemember respon sible for the care of a child; disability or severe mental illness of a parent; or a serious accident or injury to multiple family members that places important responsibilities on the servicemember. The most common forms of deferment are for medical injuries, illnesses, or family hardships that will extend beyond several months. For example, servicemembers who are battling cancer may receive an extended deferment until they are able to recover from their illness. Similarly, service members dealing with shortterm psychiatric conditions are often granted deferments because their disorders and medicines would preclude them from any deployment. These instances are very rare because shortterm problems usually result in a delay or a deferment while permanent difficulties result in a com plete separation. While each service deter mines its own policy on exemptions, and these policies can be modified from time to time, exemptions are the exception to the rule and are rarely granted. The American Veterans and Servicemembers Survival Guide 495 Separation the fourth option preventing a servicemember from being mobilized to active duty is administrative discharge from the military. Most of the reasons for separation from inactive duty mirror the reasons for separation from active duty. In some cases, the servicemember ideally should approach the command prior to receiving orders. To approach the command, the servicemember should first gather evidence and support for the request. Kinds of support to gather are letters from appropri ate professionals, family members, and friends; medical or court records; and official records such as birth certificates, marriage licenses, and adoption pa 11 Contrary to popular belief, you no longer need to be a sole surviving son or daughter to request a discharge. Rather, you need only be a surviving son or daughter or even a surviving brother or sister. The only requirement is that someone in your immediate family was killed, captured, missing, or 100% disabled while serving in the armed forces. Currently, there is not enough information about this system to see if it adequately resolves the problem. In response to the wars in Iraq and Afghanistan, the Army has set up a tollfree Mobilization Hot Line at (800) 3254361 that may be able to answer some of your mobilization questions. Additionally, many of the directives and regulations concerning mo bilization can be found at In the alternative, these regulations can be found by doing an Internet search for the specific service regulation you are looking for. In addition to having an abundance of information on their WebPages, these organizations can help you reach out to other veterans or to veterans groups as well as counseling groups to help ensure you understand your rights and to help assist you in resolving your specific problem. The American Veterans and Servicemembers Survival Guide 497 Major Brian Baldrate received his B. As a scout platoon leader, Brian deployed to Kuwait and trained coa lition forces in developing a plan for Kuwaiti national defense while performing reconnaissance and security of the IraqiKuwaiti border. He was valedictorian of the law school and editorinchief of the Connecticut Law Re view. Following law school, Brian served as a criminal prosecutor for the Third Armored Cavalry Regiment, where he prosecuted numerous federal felonies in cluding drug distribution, rape, and attempted murder. There he advised commanders on the laws of armed conflict and led sensitive investigations involving fratricide, war crimes, and allegations of detainee abuse. Brian received the Bronze Star Medal for his efforts in bringing the firstever trial before the Central Criminal Court of Iraq and leading efforts to restore the Iraqi judicial system in Anbar Province. Sullivan For many people, separation and divorce rank second only to the death of a loved one in terms of emotional turmoil, pain, and stress. The purpose of this chapter is to provide an overview of the process and clarify the legal pro cedures. A good lawyer can help in establishing your goals and propose a positive strategy to achieve realistic results. There are five issues which may be involved in the breakup of a marriage: property division, alimony, child support, custody/visitation, and divorce. At the outset it is important to note that not all states handle divorce in the same way. All issues must be resolved by the parties (through agreement) or by the court (through trial) before the divorce is granted. The other issues in the case are raised by law or court rule, and when one party files for divorce, all issues are presented to the court for a decision. The American Veterans and Servicemembers Survival Guide 499 In other states, such as Delaware and North Carolina, a lawsuit for divorce is not necessarily joined with the other issues. These other issues may be pre sented to the court before or after the lawsuit for divorce is filed. Custody may be contested or settled in a different lawsuit or joined in the divorce suit. Parties may resolve these and other issues through court decision or outofcourt agreements. Each of these issues can be heard by the court on different timetables, before or after the divorce. Understanding the impact of filing for divorce, the issues that are involved (or kept separate), the timetables and the deadlines would be the starting point. Going to Court If you must litigate (participate in a lawsuit), you need to know something about the process. Litigation always starts with the filing of a complaint or petition along with a summons. The complaint or petition states the facts of the case and what relief is re quested. The summons states that the other side has been sued and has a certain period in which to respond. Depending on state or local rules, additional documents may have to be filed by the parties. They include financial affidavits or declarations, stating the incomes and expenses of each party, or property inventories, showing what each party claims to be marital or separate property and debt, as well as the value claimed for each item. Sometimes courts also require parties to file a copy of tax returns, pay stubs or other financial documents. While the entire case is pending, temporary, interim, or emergency hearings may be requested. Courts often consider the need for interim spousal support or child support at a temporary hearing in the weeks or months after a case is filed. This is a short hearing, perhaps a couple of hours in length, to allow immediate decisions on important matters which need to be decided 500 Women Servicemembers and Veterans promptly. This is often done to protect the financially disadvantaged spouse during the divorce process. Some courts use the time after filing to conduct a hearing on interim allocation, which means a temporary division or distribution of marital assets pending the final hearing. This also can be useful in providing each party with sufficient means to pay the lawyers, psychologists or account ants required to assist in resolving the case or preparing for trial. Many state court rules allocate to discovery the first 90120 days after the lawsuit has been filed. An attorney can also request certain papers, receipts, titles, or deeds from the other side. Although no penalties or sanctions are incurred for failure to produce or reply (as is the case with formal discovery), considerable time and money can be saved if the parties and their lawyers are willing to cooperate. Formal or traditional discovery, on the other hand, has structures, dead lines, definitions and rules that must be obeyed. Here are some examples: the American Veterans and Servicemembers Survival Guide 501 Interrogatories are written questions that are sent to opposing counsel. They must be answered by the opposing party under oath within a certain number of days (usually around 30). Document requests require the other side to produce documents at a specified place and time for inspection and copying. It results in a computerprinted transcript of the testimony and it can be very useful in exploring what facts or data the other side has, what accusations will be made, and how the other side is thinking about the case. Lawyers frequently prepare written briefs that summarize and explain points of law that may be at issue in the case. Some times there is a pretrial conference with the judge to organize the case and focus the issues. Yes, there are other people get ting a divorce, and yes, they also have their cases set on your day! Then the witnesses for the plain tiff testify and are crossexamined by the other side. If the par ties do not participate in the decision conference, they will be notified by their attorneys. Sometimes this is done by the court, and sometimes the attorneys write up a decision for the judge to sign. This often requires their meeting together or with the judge while they are preparing findings of fact for the judge on contested issues. This process can take days, weeks, or even months in a complex or hotly contested case. Alternatives to trial There are several nontrial options worth considering: mediation, collabo rative law, coaching, and negotiation. If handled correctly, these options generally are less expensive and less timeconsuming than a trial. Mediation is informal dispute resolution in which a neutral third party, a trained mediator, helps you and your spouse reach an agreement. The mediator does not make deci sions, but rather encourages both parties to work together to make their own decisions. Mediation is an increasingly popular option and generally much cheaper than a trial. Sometimes a free or inexpensive courtsponsored media tion program is available for part or all of a case. Every state has its own the American Veterans and Servicemembers Survival Guide 503 requirements for mediation.

Foods Vitamin D naturally occurs in very few foods diabetic diet 600 calories per day buy precose australia, mainly in the flesh of fatty fish diabetes signs toddler purchase precose american express, some fishliver oils diabetes vaccine purchase 25mg precose overnight delivery, and eggs from hens fed vitamin D diabetes insipidus nutrition effective 25 mg precose. The potential effects of vitamin D deficiency include the following: Rickets (in children) O steomalacia (in adults) Elevated serum parathyroid hormone D ecreased serum phosphorus Elevated serum alkaline phosphatase O steoporosis (porous bones) Epidemiological studies have found an association between vitamin D defi ciency and an increased risk of colon 55 diabetes diet buy precose 50mg fast delivery, breast diabetes symptoms in women type 1 purchase generic precose line, and prostate cancer in people who live at higher latitudes. Adults over the age of 65 years produce four times less vitamin D in the skin compared with adults aged 20 to 30 years. An increase in skin melanin pigmentation or the topical use of sunscreen reduces the production of vitamin D3 in the skin. The adverse effects of hypervitaminosis D are probably largely medi ated via hypercalcemia. As adults age, their ability to synthesize vitamin D in the skin significantly decreases. Little information exists on the adverse effects that might result from ingestion of other forms. Other naturally occurring forms of vita min E do not meet the vitamin E requirement because they are not converted to atocopherol in humans and are poorly recognized by the atocopherol trans fer protein in the liver. Little information exists on the adverse effects that might result from the ingestion of other forms of vitamin E. Overt deficiency of vitamin E in the United States and Canada is rare and is generally only seen in people who are unable to absorb the vitamin or who have inherited conditions that prevent the maintenance of normal blood concentra tions. The possible chronic effects of lifetime expo sures to high supplemental levels of atocopherol remain uncertain. Its major function seems to be as a nonspecific chainbreaking antioxidant that prevents the spread of freeradical reactions. It scavenges peroxyl radicals and protects polyunsaturated fatty acids within mem brane phospholipids and in plasma lipoproteins. It may also improve vasodilation and inhibit platelet aggregation by enhancing the release of prostacyclin. Vitamin E is excreted in both the urine and feces, with fecal elimination being the major mode of excretion. These various forms of vitamin E are not interconvertible in humans, and thus do not behave the same metabolically. Since the 2Sstereoisomers are not maintained in the plasma or tissues, they are not included in the definition of active components for vitamin E activity in humans. For the purpose of establishing the requirements, vitamin E activity is de fined here as being limited to the 2Rstereoisomeric forms of atocopherol. Although some studies have reported a possible protective effect of vitamin E on conditions such as cardiovascular and neurological diseases, can cer, cataracts, and diseases of the immune system, the data are inadequate to support populationwide dietary recommendations that are specifically based on preventing these diseases. Little information exists on the adverse effects that might result from ingestion of excess amounts of other isomeric forms (such as g and btocopherol). Currently, most nutrient databases, as well as nutrition labels, do not dis tinguish among all the different forms of vitamin E found in food. The risk of adverse effects resulting from excess intake of atocopherol from food and supple ments appears to be very low based on this information. Indi viduals who are deficient in vitamin K or who are on anticoagulant therapy are at increased risk of coagulation defects and should be monitored when taking vitamin E supplements. It is important to note that because vitamin E is generally found in fat containing foods and is more easily absorbed from fatcontaining meals, in takes of vitamin E by people who consume lowfat diets may be less than opti mal unless food choices are carefully made to enhance vitamin E intake. Of the women surveyed, 49 percent used supplements, and 73 percent of them took a vitamin E supplement. Dietary Interactions There is evidence that vitamin E may interact with certain dietary substances (see Table 3). With regard to supplemental vitamin E intake in the form of synthetic tocopherol (as a supplement, food fortificant, or pharmacological agent), most studies in humans showing the safety of vita min E were conducted in small groups of individuals who received supple mental amounts of 3, 200 mg/day or less (usually less than 2, 000 mg/day) of tocopherol for periods of a few weeks to a few months Thus, the possible chronic effects of longer exposure to high supplemental levels of tocopherol remain uncertain and some caution must be exercised in judgments regarding the safety of supplemental doses of tocopherol over multiyear periods. The potential adverse effects of excess vitamin E intake include hemorrhagic toxic ity and diminished blood coagulation in individuals who are deficient in vita min K or on anticoagulant therapy. Special Considerations Premature infants: Hemolytic anemia due to vitamin E deficiency is of frequent concern in premature infants. However, its management via vitamin E supple mentation must be carefully controlled because small premature infants are particularly vulnerable to the toxic effects of tocopherol. Folate is a generic term that includes both the F naturally occurring form of the vitamin (food folate or pteroyl polyglutamates) and the monoglutamate form (folic acid or pteroylmonoglutamic acid), which is used in fortified foods and dietary supplements. Rich food sources of folate include fortified grain products, dark green vegetables, and beans and legumes. Since foods fortified to a level of 400 mg are not available in Canada, the recommendation is to consume a multivitamin con taining 400 mg of folic acid every day in addition to the amount of folate in a healthful diet. The term folate refers to two forms: naturally occurring folates in food, referred to here as food folates (pteroylpolyglutamates), and folic acid (pteroylmonoglutamic acid), which is rarely naturally found in foods but is the form used in dietary supplements and fortified foods. Folate is taken up from the portal circulation by the liver, where it is metabolized and retained or released into the blood or bile. To reduce the risk of neural tube defects, women able to become pregnant should take 400 mg of folic acid daily from fortified foods, supplements, or both, in addition to consuming food folate from a varied diet. It has been recognized that excessive intake of folate supplements may obscure or mask and potentially delay the diagnosis of vitamin B12 deficiency. These indi viduals may place themselves at an increased risk of neurological disorders if they consume excess folate because folate may mask vitamin B12 deficiency. However, as of January 1, 1998, in the United States, all enriched cereal grains, such as bread, pasta, flour, breakfast cereal, and rice, are required to be fortified with folic acid at 1. In Canada, the fortification of all white flour and cornmeal with folate is at a level of 1. Dietary Supplements Folic acid supplements in doses of 400 mg are widely available over the counter. Supplements containing 1, 000 mg or more are available by prescription in the United States and Canada. No pub lished information was found regarding the effect of food on the bioavailability of folate supplements. Dietary Interactions There is evidence that folate may interact with certain nutrients, dietary sub stances, and drugs (see Table 2). Nonsteroidal Very large therapeutic Routine use of low doses of these drugs has not anti doses. Methotrexate Chronic methotrexate It has been recommended that patients undergoing therapy may impair folate chronic methotrexate therapy for rheumatoid status. In contrast to folate deficiency, iron defi ciency leads to a decrease in mean cell volume. A vitamin B12 deficiency results in the same hematological changes that occur with folate deficiency because the vitamin B12 deficiency results in a sec ondary folate deficiency. The adverse effect that may result from excess intake of supplemental folate is the onset or progression of neurological complications in people with vitamin B12 deficiency. Excess folate can obscure or mask and thus potentially delay the diagnosis of vitamin B12 deficiency, which can result in an increased risk of progressive, unrecognized neurological damage. Rich dietary sources of vitamin K include leafy green vegetables, soy and canola oils, and margarine. Clinically significant vitamin K defi ciency is extremely rare in the general population, with cases being limited to individuals with malabsorption syndromes or to those treated with drugs known to interfere with vitamin K metabolism. It also plays an essential role in the conver sion of certain residues in proteins into biologically active forms. The liver, which contains the highest concentration of vitamin K in the body, rapidly accumulates ingested phylloquinone. Although the content is extremely variable, the human liver contains about 10 times as much vitamin K as a mixture of menaquinones than as phylloquinone. Clinical intervention studies investigating the relationship between vitamin K and osteoporosis are currently being conducted in North America and Europe. Whether vitamin K status within the range of normal intake plays a significant role in the development of atherosclerosis requires further investigation and should be verified in studies that employ rigorous experimental designs. Special Considerations Newborns: Vitamin K is poorly transported across the placenta, which puts newborn infants at risk for vitamin K deficiency. The phylloquinone content of plant oils varies, with soybean and canola oils containing greater than 100 mg of phylloquinone/100 g. Cottonseed oil and olive oil contain about 50 mg/100 g, and corn oil contains less than 5 mg/100 g. This form of vi tamin K is more prevalent in margarines, infant formulas, and processed foods, and it can represent a substantial portion of total vitamin K in some diets. It is known, how ever, that the absorption of vitamin K from vegetables is enhanced by the pres ence of dietary fat. Dietary Interactions the main interaction of concern regarding vitamin K involves anticoagulant medications, such as warfarin. Individuals on chronic warfarin therapy may require dietary counseling on how to maintain steady vitamin K intake levels. How ever, changes in supplemental vitamin K intake should be avoided, since the bioavailability of synthetic (supplemental) phylloquinone is considerably greater than the bioavailability of phylloquinone from food sources. In general, clinically significant vitamin K deficiency is extremely rare in the general population, with cases being limited to individuals with various lipid malabsorption syndromes or to those treated with drugs known to interfere with vitamin K metabolism. A search of the literature re vealed no evidence of toxicity associated with the intake of either the phyllo quinone or the menaquinone forms of vitamin K. A few green vegetables (collards, spinach, and salad greens) contain in excess of 300 mg of phylloquinone/100 g, while broccoli, brussels sprouts, cabbage, and bib lettuce contain between 100 and 200 mg of phylloquinone/100 g. This value is not determinable due to the lack of data of adverse effects in this age group and concern regarding the lack of ability to handle excess amounts. There are no adverse effects associated with the excess consumption of naturally occur ring niacin in foods, but they can result from excess intakes from dietary supple ments, fortified foods, and pharmacological agents. Bioavailability Niacin from meat, liver, beans, and fortified or enriched foods appears to be highly bioavailable, whereas niacin from unfortified cereal grains is bound and only about 30 percent available (although alkali treatment of the grains in creases the percentage absorbed). Dietary Interactions There is some evidence that inadequate iron, riboflavin, or vitamin B6 status increases niacin needs by decreasing the conversion of tryptophan to niacin. Now it is occasionally seen in developing nations, such as in India, China, and Africa. Deficiencies of other micronutrients, such as pyridoxine and iron, which are required to convert tryptophan to niacin, may also contribute to the appearance of pellagra. Also, pregnant females who are carrying more than one fetus or breastfeeding more than one infant may require additional niacin. But adverse effects may result from excess niacin intake from dietary supplements, pharmaceutical preparations, and fortified foods. Pantothenic acid deficiency is rare, and no adverse effects have been associated with high intakes. Absorption, Metabolism, Storage, and Excretion Pantothenic acid is absorbed in the small intestine by active transport at low concentrations of the vitamin and by passive transport at higher concentra tions. Food processing, including the refining of whole grains and the freezing and canning of vegetables, fish, meat, and dairy products, lowers the pantothenic acid con tent of these foods. Riboflavin deficiency (ariboflavinosis) is most often accompanied by other nutrient deficiencies, and it may lead to deficiencies of vitamin B6 and niacin, in particular. Diseases such as cancer, cardiac disease, and diabetes mellitus are known to precipitate or exacerbate riboflavin deficiency. Its apparent nontoxic nature may be due its limited absorption in the gut and its rapid excretion in the urine. The rate of absorption is proportional to intake, and it increases when riboflavin is ingested along with other foods and in the presence of bile salts. In the plasma, a large portion of riboflavin associates with other proteins, mainly immunoglobulins, for transport. Pregnancy increases the level of carrier proteins available for riboflavin, which results in a higher rate of riboflavin uptake at the maternal surface of the placenta. In newborns, urinary excretion is slow; however, the cumulative amount excreted is similar to the amount excreted by older infants.

I will never forget the sinking feeling I got when I read her muchvaunted thesis prediabetes definition hba1c discount 25 mg precose amex. As I read further and further into the thesis diabetes treatment options buy generic precose from india, there was not a single original statement or new insight diabetes in toddlers order cheap precose on line. I had known for some time that the academic community does not allow personal observation (if you doubt that diabetes mellitus values order precose 50mg overnight delivery, just try to insert your own observations and experiences in an academic paper and see what the response is diabetes mellitus español buy line precose. After this experience I quit either looking up to my academic mind or looking down on my big original spontaneous fiunsophisticatedfi intui tive intelligence diabetes prevention education generic precose 25 mg otc. This boy began to stutter horribly a few years before, when he was made conscious that he stuttered and effort was made to try to fix his stuttering (just as my stuttering had changed from about 1 on the Richter scale to l0 when I became conscious of speaking and tried to fix my stuttering. Right in the mid dle of all the ficuresfi he was offered, along with numerous rules, shoulds, expectations, and lack of hope (everyone assured him that there was no possibility he would ever be cured since fistuttering is inherited and there is no hope of a curefi) this child simply stopped speaking. While I was realizing that it is the spontaneous and automatic intelli gence that is in charge of both what I say and how I say it (scientists assure us that both con tent and translating content into symbols are spontaneous). But I kept telling myself fiOther people must not be affected by tryingtoo hardtospeak or I would hear about it from other people who stutter. To me, this child who had lost the will to speak was like a sick person who loses his will to live. I was starting to get angry at things I had put up with all my life up to that timebecause I was able to see the effects on children with their whole lives ahead of them. I started a diet and as soon as it began to work I noticed that others tried to sabotage my new lifestyle. One day this question came to me: fiSo you see all the sabotage going on out here, rightfi The next morning I was heading to the doctor for a weighin, full of resolve, full of energy, full of good intentions. So there I was, driving along, when suddenly I noticed something I had not allowed myself to observe before. Mary is skinny as a stick and she eats sugar and those wonderful German yummy pastries all the time. I sat down on a couch and got out my notebook and wrote: fiWhat has ruined my resolvefi You came in here this morning full of hope and resolve and good intentions and look at you now. Miracle workers have said that resistance to crea tive energies prevents them from performing great miracles. Jesus himself, it is said, could do no mighty works because of unbelief and unbelief is simply a very formidable form of resistancetothemax. I or dered my critical jabbering mind to just shut the hell up and stop ruining my life. This was a complete reversal from my imagination in charge of eating and speaking. It was as if my fiobserverfi was on my side to the extent of taking charge and protecting me from my chattering mind. I found that when I spoke quick ly without thinking about what I was going to say or how I was going to say it, speech was au tomatic and fluent. Next you must tighten the biceps to bend your elbow and rotate your shoulder to raise your arm while cocking your wrist at the top of the swing. All this and more just in order to get the hammer in position before bringing it down on the head of the nail! Then comes the amazingly complex handeye coordination which guides the hammer to the nail head. Here is something I hope will be heartening to you because it is so solid, so true: the truth was I was not going to speak more fluently by strangling myself. When I final ly got it that my conscious, learned, educated intellect actually ruined my speech, at that exact moment a monumental breakthrough occurred. Regardless of the name we give to this New Self, I knew that no permanent change was possible without observing the problem first. All change for me was preceded with being able to observe what was going on and it was this New Self that handled the work of observa tion. All selfknowledge (so necessary to growth) is only possible through objective observa tion. The ability to observe enables us to perceive aspects of reality our laborious deductive logic has no access to . For example, a leader of one of the classes I attended told us to tell our top 3 core values. A woman I knew very well who was known for her almosttotal narciss ism stood to her feet and said fiI value God first, others second, and myself last. This event left me with the insight that without this activity I then referred to as fiobjec tive Observationfi we are all in deep doodoo. As soon as I actually figot itfi that speech could not be forced or manufactured or fiwilled, fi that insight affected the behavior I call fistuttering. I observed the results of shoulds, would, could, likes and dislikes and saw how they were able to mess with my resolve. For three whole months I made a promise to myself not to read a single book or book reviews, or any other interpretative text about stuttering. In this kind of discipline there is no suppression, there is no suppression in the discipline that is necessary in order to see. So the observer watches pleasure and sees that the continuity of pleasure is created by thought. A di mension in which I have to work very hard (at observing) and which nobody is going to tell me about. In doing so, we downplay our own ability to make significant discoveries through selfobservation and by observing the behavior of others. Each was able to speak from a unique position of authoritythat is, from the point of view of his or her own experience. These individuals have known how to use their observations to work through the complexities that underlie their own stuttering syndrome. Put in another way, I observed Control, Disruption (stuttering), and Fear: 1) Attempting to control speech was the primary culprit when it came to stuttering. Stuttering always seemed to go back to its source: the result of my conscious mind building a dam over the flowing river in order to control what was meant to be a flowing spontaneous activity. As long as my Inner Control Freak was in charge of speaking, no flow was going to happen. Stuttering was the product of my own control system (controlling by beliefs, imagination, wrong priorities, and rigidly resisting the flow). Until I got really, really, really angry at this whole control system, I was still bound by it. The greatest paradox seemed to be to be the truth fiThe harder I try, the worse I get. I was the Witness who observed my stutter, who looked at what was going on without judgment (this is good, this is bad, this should be, this should not be. I notice centering on technique erases my content (thinking of fihowfi erases fiwhat I want to say. That was a pretty sly trick as I see it now, because the crux of the stuttering conflict for me had to do with getting Big Me and Little Me to work together, thus erasing the conflict. So when I inadvertent ly engaged Little Me in the difficult work of writing my observations down on paper I was doing exactly that: creating unity between Big Me and Little Me. My attitude toward writing changed because every day I would write new things I had never written or even thought of prior to that time. One day as I was writing about stuttering I wrote this: fiThere is a block in my throat around which I have to blow air. A discovery that might have taken a psychiatrist 30 years to discover revealed itself to me through writing my observations. I must add here, however, that there were all kinds of versions of that belief I had to deal with, but as far as that particular belief was concerned. I could see I was creating monsters with my imagination and these monsters served as blocks in my speech. At this poing I noticed my imagination was the source of nutty beliefs and incredible fear. It was similar to when my kids were small and manufactured boogiemen in their imaginations which, in turn, scared them nearly out of their wits. All I had to do to get rid of the boogiemen was to walk into their bedroom and turn on the lightand poof, boogiemen gone. When I am free to look and see whatever is fitherefi I am happy because I am not having to come up with certain prescribed answers. These moments of pure observation are not rare moments for me now and it is true that observation changes things (as Quantum Physics teaches. My Observer stepped out of the unknown and gradually took control away from my Critic. The very moment we start clinging to the known (or what we believe is fiknownfi) is the same moment we stop looking. It came to me that I was going to get acquainted with my resistant destructive mind. I saw that observing my thoughts, beliefs and fears was the opposite of being driven by my thoughts, beliefs and fears. Ram Dass wrote: fiThe problem comes when we want to cling to a particular thought or idea. I noticed when speech was flowing easily, my busy chattering brain came up with numerous alternatives or rules or shoulds or suggestions when I was speaking, and this interfered with my resolve, content and expression itself (which turned out to be interference with flow and fluency. I simply lis tened to the nonstop chatter (fibut that should not befi or fithis really ought to workfi). Through being the Witness to what was going on I was able to observe major forms of resistance: obstacles, wrong beliefs, resistant atti tudes, and discovered to my delight that, as quantum scientists have told us many times, fiOb servation changes things. I found later that to look up to the academic mind is to look down on the natural spon taneous intelligence outside the control of my conscious mind. Malcolm Gladwell (explaining the academic attitude) wrote about their contempt for the natural mind. Because every one in that room had not one mind but two, and all the while the conscious mind was blocked, their unconscious was scanning the room, sifting through possibilities, processing every con ceivable clue. Theodore Reik wrote in the Third Eye about this innate but subliminal ability we all possess but which does its work fiundergroundfi or outside the control of the conscious mind. This is what he wrote: fiA little known and concealed organ receives and transmits the secret messages of others before he consciously understands them himself. It is remarkable that the unconscious station which does almost all the work is left out of analytic discussions. Imagine discussing the science of sound/acoustics, without mentioning the ear, or optics without speaking of the eye. The scientific mind, dependent on the observant creative mind for its survival, often denies the existence of Observation. The conscious mind generally tends to brush aside observations of this sort as immaterial and inconsequential, little things not worthy of our atten tion. The observer sees in a microsecond what it would take the mind a very long time to comprehend. And all of this is going on outside the control of the conscious mind and has nothing to do with volition. I would be tempted to back a theory regarding stuttering that was popular at the time, but then if I kept my eyes open long enough and operated from an innocent point of view (no agenda), I finally came around to supporting my own observations.

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