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Battles Sign (of temporal fracture): bruising behind the pinna Ear Testing Voice Testing Tuning fork tests: Rinne Test: 512 Hz fork beside the ear hydroxyzine 10mg visa. If sensorineural buy hydroxyzine 25 mg otc, air conduction best Weber Test: Tuning fork on top of the head order hydroxyzine 25 mg overnight delivery. Louder in affected ear if conductive loss, softer in affected ear if sensory loss Pure Tone Audiometry: Can establish severity of hearing impairment and whether sensorineural or conductive Measures thresholds across a range of frequencies. Eustachian tube obstruction Otoacoustic emissions: Test for cochlear function, eg in neonatal screening Also for tinnitis: is it cochlear or non-cochlear Paediatric testing: 0 3 months: referred from neonatal high-risk register. Need to correct (eg hearing aid implants) by 9 10 months otherwise speech impairment 6 12 months: distraction testing looking for head turning, etc 1 2 years: in a room with speakers th th 150 4 and 5 Year Notes Hearing Loss See Hearing, page 580 for developmental delay resulting form hearing loss Congenital Sensorineural Deafness Irreversible Pathology: problems with nerve or cochlear Profound hearing loss at birth: 2 per 1,000 Most often detected by parents (ie believe them! Can be: Secretory diarrhoea: large volume Osmotic diarrhoea: disappears with fasting Abnormal intestinal motility Exudative diarrhoea: with blood or mucus Malabsorption: steatorrhoea Constipation: Check what they mean. Umbilicus is shallow or everted in ascites or pregnancy Gastro-Intestinal 155 Veins. Bend knees up if necessary to relax muscles Gently all round: look at face check for tenderness/peritonism, obvious lumps. Check for shifting dullness More firmly: looking for organs, masses What to palpate for: Liver: Dont usually feel in normal adult, may in child. Start palpation inferior to the umbilicus Kidney: if palpable either tumour or obstructed Aorta: can nearly palpate in most people key issue is width Gallbladder: Murphys sign: lay fingers along costal margin, patient takes a deep breath and it hurts. Enlarged gallbladder is unlikely to be gallstones as chronic gallstones fibrosis that cant then expand. Can be voluntary or involuntary (latter suggests peritonitis) Rigidity: muscles tight Rebound tenderness: push down surreptitiously then remove hand quickly watch face for pain (peritonitis) Percuss for: Liver Spleen: unreliable Kidneys: but overlying bowel makes this problematic Bladder: supra-pubic dullness indicates upper border of an enlarged bladder or pelvic mass Shifting dullness in ascites Ausciltate: Bowel sounds: just below umbilicus. Only part of bowel with faeces If they have ulcerative colitis shouldnt be bigger than 5cm otherwise toxic megacolon Transverse diameter of caecum shouldnt be bigger than 9 cm otherwise risk of rupture Small bowel: circularis goes right round. Gas if obstructed, diarrhoea, ileus or swallowing gas due to pain Gas under diaphragm = pneumo-peritoneum Can have gas in bilary tree (esp. Needs to be warm on arrival in lab Barium Enema Make sure they got to the caecum (i. But also specialised stuff Teeth and Teeth forming tissue: Genetic defects Severe illness eg measles bands on teeth Tetracycline discolouration Vomiting, regurgitation (eg bulimia) erosion Cysts or tumours of teeth forming tissue (eg ameloblastoma) Gastro-Intestinal 157 Gums: loose more teeth through gum disease than caries. Immunosuppressive disease can lead to abnormal gums (eg leukaemia) Salivary glands: Calcification in duct of major gland blockage Tumours/cysts Recurrent infections: short/wide ducts retrograde flow infection with oral commensals Post-radiotherapy to head and neck. Salivary tissue very sensitive dry mouth Drug induced dry month: made worse by anxiety, smoking, dehydration Sjogerns Disease: autoimmune attack of salivary and lacrimal glands Dry mouth rapid tooth decay (no buffering from saliva) Oral Mucosa: Hyperkeratosis with hyperplasia or atrophy: looks white Upsets to normal flora. Gastro-Intestinal 159 Exclude bilary colic, pancreas and heart pain Functional/idiopathic/essential dyspepsia = all investigations normal but still pain = Up to 60% of dyspepsia. H Pylori gastritis Abdominal pain without significant pathology very common Ask about weight: if overweight think reflux, if loosing weight think cancer Oesophagitis doesnt cause anaemia until proved otherwise Types: Reflux like heartburn/regurgitation treat with empiric H2 antagonist Dysmotility like bloating, nausea, fullness (? Predisposes to cancer Ulceration, stricture (always biopsy strictures as some cancers present like this) Adenocarcinoma Hiatus Hernia Common. Usually affects body of the stomach Helicobacter pylori infection: Hypertrophic gastritis: enlargement of rugal folds due to hyperplasia. Differential: lymphoma can also present with enlargement of rugae Acute Ulcers Stress ulcers: shock, burns, sepsis Due to mucosal hypoxia Usually heal quickly Appearance: multiple circular ulcers < 1cm. Eradication only of benefit if ulcers present Microscopic appearance: chronic atrophic gastritis. Reinfection is rare (< 1%) 2 weeks optimal 7 days pretty good pH has effect on antibiotic bioavailability: want to pH (e. A diary free diet pre-diagnosis may have improved things as less lactase in coeliac disease ? Family screening: but antibodies only +ive with mucosal damage (doesnt detect latent disease). Keep kids growth charts up to date Refer patients to Ceoliac Society Other Malabsorption Syndromes Lactose Intolerance: Lactose intolerance very common: especially where diary products are uncommon. If lactase then osmotic diarrhoea rapid transit early & large rise in H2 as lactose is broken down by bacteria. Check with serial breath H2 measurements Tropical Sprue: Enterotoxic E coli infection in visitors to the tropics. Gallstone moves from gallbladder to duodenum via fistula ( air into bilary tree). Especially around ileocaecal valve Also in large bowel: Diverticular stricture and cancer (most common in sigmoid) Volvulus: of any part of colon (especially sigmoid) Distal obstruction can also cause ileocaecal valve to shut close loop obstruction. Caecum ischaemic first as biggest radius (Law of La Place) Pseudo-obstruction: motility problem (esp. If dose is bad enough to need another then need surgery If no scars & no hernias surgery If scars may settle (if operate more adhesions). Regular review Appendicitis = Acute Suppurative Appendicitis Lifetime incidence = 6% Most common surgical emergency Incidence declining (? If no diarrhoea or vomiting then no immediate danger of dehydration If you diagnose it, or if you dont, youll be wrong 50% of the time! Symptoms & Signs Very difficult to diagnose considerable variety in presentation Fever: 37. In a child, look for tenderness and guarding not rebound wont let anyone touch them after that. Mucinous cystadenocarcinoma invading the peritoneum, fills with tenacious semisolid mucus. Pathology Macroscopic appearance: Begins in rectum and extends in continuity to left colon. Acute dilation of colon due to loss of muscle tone gas distension vascular occlusion necrosis. Key risk facts: How long have they had it (main one): 1% at 10 years, 30% at 30 years. Minimal with only rectal involvement How well controlled is the inflammation Aggressive flat lesions, infiltrates quickly into lymphatics in submucosa Perforation Fibromuscular strictures (check to exclude malignancy) Treatment Sulphasalazine +/- steroids (or azathioprine). Surgery for Colectomy = cure obstruction and abscess common Small Bowel Tumours Benign: Polyps (Peutz-Jeghers), Juvenile Polyps, Adenomas, Stromal tumours Malignant: Carcinoid tumours: Tumours arising from neuroendocrine cells Mainly midgut. Appendix and rectum better, ileal and colonic worse Carcinoid Syndrome: due to excess serotonin. Resembles those in the colon Colorectal Cancer Presentation Change in shape of stools significant (e. Referral to plan appropriate surveillance Incidence has been declining since 1950s (5. Normally removed as dont know which will become invasive Malignancy related to size: <1. Head has closely packed tubules/glands lined by non-differentiated neoplastic columnar cells. May secrete lots of mucous Juvenile polyps: Left side of large bowel of kids Cause rectal bleeding Grossly look similar to adenomas Microscopically not neoplastic.

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Overall buy 10mg hydroxyzine with visa, at the fve-year follow-up buy hydroxyzine 10 mg without prescription, the and recovery takes between 18 and 24 months buy cheap hydroxyzine 25 mg line. If this artery is ment-related sexual dysfunction in damaged during surgery, erectile tissue oxygen- male cancer survivors ation will be broken down [21]. Phosphodiesterase-5 inhibitors Gonadal testosterone is the main source of an- drogen. Since the primary erectile problems afer surgery are relat- cancer, its impact on quality of life remains con- ed to hypoxia due to innervation or ischemia, pe- troversial. Hormone deprivation may result in a nile tissue oxygenation might be maintained by decrease in the size of the penis and testicles, loss sustained erections. Dysfunction resulting from radiotherapy timal timing for usage is one hour before sexu- External beam radiation therapy is one of the al intercourse. It is important to note that these principle treatment options for localized prostate agents can cause severe hypotension and syncope cancer and has similar progression free survival if used with nitrates. During this therapy, the ra- recommended for patients on nitrate treatment diation dose is delivered to the bulb of the penis. Sildenafl is recommended at doses of 50 mg; Corporal bodies seem to be associated with radi- however, if well tolerated, this may be elevated ation-induced impotence due to penile strictures to 100 mg in order to achieve sufcient results. Vardenafl is available in 5,10, within the frst two years, whereas fbrosis afer and 20 mg forms. In the past, these agents were believed to within 30 minutes to avoid hypoxic injury of the cause myocardial infarction and sudden death; penis. The deaths could have been related directly tion rate is low, and there is no clear contraindica- to the act of sexual intercourse itself [31,32]. Urethral suppositories and penile self-injection with severe neural or hypoxic injuries, initiating agents erections might be impossible. Patients who do not re- ofen result to priapism when compared with spond to these medical options should be referred intraurethral applications. Sexual dysfunction from various and might be a satisfactory option for patients to surgical and medical approaches is ofen underes- avoid cardiac toxicity. Nerve-sparing radical of exemestane versus continued tamoxifen afer 2 to hysterectomy for cervical carcinoma. Crit Rev Oncol 3 years of tamoxifen in postmenopausal women with Hematol 2009;70:195205. Sexual prob- dysfunction in postmenopausal breast cancer patients lems in younger women afer breast cancer surgery. Incidence of outcomes afer prostatectomy or radiotherapy for chemotherapy-induced amenorrhea in premenopau- prostate cancer:the prostate cancer outcomes study. J sal patients with breast cancer following adjuvant Natl Cancer Inst 2004;96:13581367. Quality of life study of postoperative nightly sildenafl citrate for in long-term, disease free survivors of breast cancer:a the prevention of erectile dysfunction afer bilateral follow-up study. Breast Can- rate in men with erectile dysfunction following radi- cer Res Treat 2002;75:241-248. Bone loss in elder- tion in men following bilateral nerve-sparing radical ly women prevented by ultra low doses of parenteral prostatectomy. Guidelines in postmenopausal women on adjuvant aromatase in- on male sexual dysfunction:erectile dysfunction and hibitors. Efcacy and safety of sildenafl citrate in women with sexual dysfunction associated with female sexu- 33. Women Health Gend Based Med safety of transurethral alprostadil in patients with 2002;11:367-377. Emerg- intracavernous injections of alprostadil:results of a ing concepts in erectile preservation following radical prostatectomy:a guide for clinicians. Int J Im- afer nerve sparing radical prostatectomy and penile pot Res 2011;23;8186. Curr Opin Urol the early use of the vacuum erection device afer rad- 2009;19:322336. Can J Urol 2011;18:5721- 9406: fndings from a prospective, multi-institution- 5725. Late onset hypogonadism was defned by Morales Erectile dysfunction and Lunenfeld as a biochemical syndrome associated The Massachusetts Male Aging Study -- a prospective, Address correspondence to Dr. In healthy lower brachial artery fow-mediated, endothelium endothelium, low levels of nitric oxide are continuously dependent and independent vasodilatation, suggesting released to keep blood vessels dilated. Nitric oxide the presence of a peripheral vascular abnormality in has three other effects. We now know that testosterone is a the potential side effects of headache, fushing, and precursor of nitric oxide and affects the ability to obtain backache. This was followed by the at erection hardness scale outcomes and reported that approval of tadalafil (Cialis) and then vardenafil 82% of men using sildenafl had an erection that was (Levitra). Originally, all three drugs were prescribed frm enough to achieve satisfactory sexual activity. The key fndings were that free testosterone laboratory tests to determine total testosterone and declined by 2. In men, testosterone defciency syndrome can begin Men who had metabolic syndrome had a 3. Not all men with low testosterone levels and signifcant health have a decrease in testosterone, and not all men are risks. Total and bioavailable testosterone are inversely affected in the same way by a decrease in testosterone. Testosterone a patient taking testosterone replacement therapy is essential for a normal erection because of its impact properly will perceive a beneft after 3 months. Some men with low Regular patient follow up is very important after testosterone levels can have normal erections, and some initiation and continued testosterone replacement men with normal testosterone have poor erections. This therapy is associated with a wide range Therefore, it is important to assess a patient for both of potential side effects including activation site effects conditions. Jack Barkin is an active urologist and Chief of Staff To date, no study has shown that replacing at the Humber River Regional Hospital in Toronto. He has replacement therapy may unmask the prostate cancer spoken all over the world for all of the companies earlier. If the cancer is identifed at an early stage, the patient has the best chance of obtaining a cure. Morales et al summarized the relationship between testosterone and the prostate, as follows. Morales A, Lunenfeld B; International Society for the Study of testosterone replacement therapy versus men receiving the Agin Male. Prevalence and risk factors for erectile Hoffman and colleagues showed that among men dysfunction in a population-based study in Iran. Int J Impot Res who were diagnosed with prostate cancer, those 2003;15(4):246-252.

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Frequency and severity of hypoglycemia Table 2 Severity of hypoglycemia negatively impact on quality of life (1) and promote fear of future hypoglycemia (2 buy discount hydroxyzine 10mg,3) cheap hydroxyzine 25 mg with amex. This fear is associated with reduced self-care Mild: Autonomic symptoms are present buy 25mg hydroxyzine free shipping. The negative social and emotional Moderate: Autonomic and neuroglycopenic symptoms are present. Islet cell transplantation, Prior episode of severe hypoglycemia which has been shown to reduce hypoglycemia (48) and restore Current low A1C (<6. Simi- Chronic kidney disease larly, pancreas transplantation has been shown to reduce Low economic status, food insecurity hypoglycemia and restore glucose counter-regulation (43,5153). The children unable to detect and/or treat mild hypoglycemia on their latter are rare and have been reported only in case studies. Risk factors for hypoglycemia in people with type 2 diabetes rent hypoglycemia may impair the individuals ability to sense sub- include advancing age (18), severe cognitive impairment (19), poor sequent hypoglycemia (54,55). Risk factors for severe hypoglycemia are the occurrence of severe hypoglycemic episodes (57,61). The mechanism for this increase is not occurs when the threshold for the development of autonomic certain. Hypoglycemia is associated with increased heart rate, mia is confusion or loss of consciousness. Severe hypoglycemia, resulting in sei- zures, is more likely to occur at night than during the day (12). Treatment of Hypoglycemia Both hypoglycemia unawareness and defective glucose counter- regulation are potentially reversible. Glucose gel is quite slow educational interventions, may benet from continuous subcuta- (<1. Severe hypoglycemia in a conscious person with diabetes should be treated 15 g of glucose in the form of glucose tablets by oral ingestion of 20 g carbohydrate, preferably as glucose tablets or 15 mL (3 teaspoons) or 3 packets of table sugar dissolved in water equivalent. With no intravenous access: 1 mg glucagon should be given subcu- taneously or intramuscularly. With intravenous access: 1025 g (2050 mL of D50W) of glucose inhibitor (acarbose) must use glucose (dextrose) tablets (79) or, if should be given intravenously over 13 minutes [Grade D, Consensus]. The effectiveness of glucagon is reduced in indi- and a protein source) should be consumed [Grade D, Consensus]. All people with diabetes currently using or starting therapy with insulin or insulin secretagogues and their support persons should be counselled about the risk, prevention, recognition and treatment of hypoglycemia. Risk factors for severe hypoglycemia should be identied and addressed Other Relevant Guidelines [Grade D, Consensus]. In people with diabetes at increased risk of hypoglycemia, the following Diabetes and Driving, p. Avoidance of pharmacotherapies associated with increased risk of Type 1 Diabetes in Children and Adolescents, p. S234 recurrent or severe hypoglycemia (see Glycemic Management in Type 2 Diabetes in Children and Adolescents, p. A standardized education program targeting rigorous avoidance of hypoglycemia while maintaining overall glycemic control [Grade B, Level 2 (83)] c. Structured diabetes education and frequent follow up [Grade C, and Bayer; and grants from Mylan. Paty reports personal fees Level 3 (42) for type 1 diabetes; Grade D, Consensus for type 2]. Mild-to-moderate hypoglycemia should be treated by the oral ingestion References of 15 g carbohydrate, preferably as glucose or sucrose tablets or solu- tion. Fear of hypoglycaemia in parents of young children with type 1 diabetes: A systematic review. Diabetes 1993;42:1683 Reduced diabetes self-care caused by social fear and fear of hypoglycemia. Diabetes and fathers of children with type 1 diabetes is associated with poor glycaemic 1994;43:142634. Risk factors of severe hypoglycaemia tomatic responses to hypoglycemia in patients with insulin-dependent diabe- in adult patients with type I diabetesa prospective population based study. Effects of autonomic neuropathy on Pancreas transplantation is associated with signicant survival benet. Nephrol counterregulation and awareness of hypoglycemia in type 1 diabetic patients. Effect of intensive therapy and automated insulin suspension vs standard insulin pump therapy diabetes treatment on the development and progression of long-term on hypoglycemia in patients with type 1 diabetes: A randomized clinical trial. Threshold-based insulin-pump diovascular disease and hypoglycaemia in patients with type 2 diabetes: The interruption for reduction of hypoglycemia. N Engl J Med 2013;369:224 Action in Diabetes and Vascular Disease: Preterax and Diamicron Modied Release 32. Phase 3 trial of transplantation of human hypoglycemia and poor diabetes self-management in a low-income sample with islets in type 1 diabetes complicated by severe hypoglycemia. Recovery of endocrine function after islet and pancreas transplan- plicating type 2 diabetes: The Fremantle diabetes study. Prevalence of impaired awareness of the safety, ecacy, and cost of islet versus pancreas transplantation in nonuremic hypoglycaemia and frequency of hypoglycaemia in insulin-treated type 2 dia- patients with type 1 diabetes. Diabetes Research in Children Network (DirecNet) Study Group, Tsalikian E, Child 1996;75:1203. Unrecognised nocturnal hypoglycaemia in insulin- glycemia in young children and adolescents with well-controlled type 1 dia- treated diabetics. Severe hypoglycaemia and cognitive impair- dren and adolescents with insulin-dependent diabetes mellitus: Prevalence and ment in older patients with diabetes: The Fremantle Diabetes Study. Effects of inten- glycemia reduce detection of clinical hypoglycemia in type 1 diabetes melli- sive diabetes therapy on neuropsychological function in adults in the Diabetes tus. Mortality and treatment side-effects during long-term inten- mia normalizes the glycemic thresholds and magnitude of most of neuroen- sied conventional insulin treatment in the Stockholm Diabetes Intervention docrine responses to, symptoms of, and cognitive function during hypoglycemia Study. The effects of type 1 diabetes Citations identified throughCitations identified through Additional citations identifiedAdditional citations identified on cognitive performance: A meta-analysis. Severe hypoglycemia and risks of Citations after duplicates removedCitations after duplicates removed vascular events and death. Effects of acute insulin-induced hypo- Title & abstract screeningTitle & abstract screening Citations excluded*Citations excluded* glycemia on indices of inammation: Putative mechanism for aggravating vas- N=1,705 N=1,484 cular disease in diabetes. Effects of acute hypoglyce- mia on inammatory and pro-atherothrombotic biomarkers in individuals with type 1 diabetes and healthy individuals. Diabetes Care 2010;33:1529 Full-text screeningFull-text screening Citations excluded*Citations excluded* 35. Effects of controlled hypoglycaemia N=221 on cardiac repolarisation in patients with type 1 diabetes. Diabetes Technol Ther Full-text reviewedFull-text reviewed Citations excluded*Citations excluded* 2010;12:2836. Relationship between hypoglycemic epi- Studies requiringStudies requiring sodes and ventricular arrhythmias in patients with type 2 diabetes and cardio- new or revised recommendations vascular diseases: Silent hypoglycemias and silent arrhythmias. Can J Diabetes 42 (2018) S109S114 Contents lists available at ScienceDirect Canadian Journal of Diabetes journal homepage: www.

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Type 1 diabetes develops most frequently in children buy hydroxyzine 25 mg on line, young people and young adults order hydroxyzine 25 mg with visa. These include increased thirst and urine production cheap hydroxyzine 25 mg on-line, weight loss despite increased appetite, tiredness and blurred vision. Type 1 diabetes is usually diagnosed as a result of the presence of a combination of characteristic symptoms plus a high blood glucose level. To prevent acute complications they also need to maintain their blood glucose within certain limits, which will require adjustments in their diet and lifestyle. If the balance between diet, physical activity levels3 and insulin dosage is not maintained, this can lead to hypoglycaemia (very low blood glucose). Type 2 diabetes is most commonly diagnosed in adults over the age of 40, although increasingly it is appearing in young people and young adults. About 85% of people with diabetes in England have Type 2 diabetes, which in many cases could either have been prevented or its onset delayed. Glucose builds up in the blood, as in people with Type 1 diabetes, but symptoms appear more gradually and the diabetes may not be diagnosed for some years. Thus, Type 2 diabetes is often detected during the course of a routine examination or investigation of another problem. Some will also need to take tablets and/or insulin to achieve control of their blood glucose level. Prolonged exposure to raised blood glucose levels damages tissues throughout the body by damaging the small blood vessels. The initial changes are reversible but, over time, prolonged raised blood glucose levels can lead to irreversible damage. Damage to the nerves supplying the lower limbs can lead to loss of sensation in the feet, thereby predisposing to the development of foot ulcers and lower limb amputation. People with diabetes, particularly Type 2 diabetes, are also at significantly increased risk of developing cardiovascular disease. This results from damage to the walls of the large blood vessels, which can then become blocked. Cardiovascular disease includes: q coronary heart disease, which can lead to angina, acute myocardial infarction (heart attack) and heart failure q stroke and transient ischaemic attacks (cerebrovascular disease) q blockage of the large blood vessels supplying the lower limbs (peripheral vascular disease) resulting in poor circulation to the legs and feet, which can cause pain in the legs on walking and can also predispose to the development of foot ulcers and amputation. These numbers will be significantly higher in those parts of the country with higher proportions of people from black and minority ethnic groups. Significant inequalities exist in the risk of developing diabetes, in access to health services and the quality of those services, and in health outcomes, particularly with regard to Type 2 diabetes. Those who are overweight or obese, physically inactive or have a family history of diabetes are at increased risk of developing diabetes. People of South Asian, African, African- Caribbean and Middle Eastern descent have a higher than average risk of Type 2 diabetes, as do less affluent people. Risk may accumulate if an individual belongs to more than one of these groups: q Type 2 diabetes is up to six times more common in people of South Asian descent and up to three times more common in those of African and African- Caribbean descent, compared with the white population. The diagnosis of diabetes may be delayed in older people, with symptoms being wrongly attributed to ageing. Older people may experience discrimination in the degree of active management offered compared with younger people. Standard 1 of the National Service Framework for Older People sets out a programme to eliminate any such discrimination. Those in the most deprived fifth of the population are one-and-a-half times more likely than average to have diabetes at any given age. Morbidity resulting from diabetes complications is three-and-a-half times higher in social class V than social class I. The presence of diabetic complications increases personal expenditure three-fold, and doubles the chance of having a carer. More than three-quarters of these costs were associated with residential and nursing care, while home help services accounted for a further one-fifth. The National Service Framework for Diabetes has been informed by the advice of an External Reference Group (membership shown in the Annex). It builds upon the vision of the St Vincent Declaration and is being published in two stages. Diabetes exemplifies the critical importance of this approach all the evidence suggests that a partnership between the person with diabetes and their clinical and support team can improve outcomes and quality of life. Preventing or delaying the onset of diabetes and good management of diabetes will contribute to the achievement of the goals in the National Service Framework for Coronary Heart Disease q National Service Framework for Older People: the prevalence of diabetes increases with age. Poorly controlled diabetes increases the risk of hospital admission and prolongs length of stay once admitted, and trebles the risk of stroke. Getting services right for people with diabetes will therefore be an important measure in delivering the standards in the National Service Framework for Older People. Improving the care of people with diabetes will reduce the development and progression of renal disease, potentially reducing the number of people who develop end-stage renal failure. Developing services that put children and young people with diabetes at the centre of care, and support them through the transition to adult services, will provide a model for the forthcoming Childrens National Service Framework. It will set out the actions to be taken by local health and social care systems, milestones, performance management arrangements and the underpinning programmes to support local delivery. Views expressed on the service models and performance indicators set out on the website will inform the work of the Implementation Group. Between them, this National Service Framework for Diabetes: Standards document and the National Service Framework for Diabetes: Delivery Strategy will set out a systematic programme to deliver a service built around the needs of people with diabetes. They herald a 10-year programme of change to enable more people to live free of diabetes, more people to live free from the complications of diabetes and their consequences; and more women to deliver healthy babies with less risk to themselves. The aims will be to empower people with diabetes through skills, knowledge and access to services to manage their own diabetes and fulfil their potential to live long lives free of the complications that can accompany diabetes. This chapter sets out the standards for the prevention and management of diabetes and for the participation of people with diabetes in decisions about their care. For each group of standards the overall aim is identified, together with the rationale for the standards and a summary of key interventions. Further details of each stage of this pathway are provided in the supporting documents published on the website. The number of people with Type 2 diabetes is rising, with an increasing number of young people being diagnosed. Some risk factors for developing diabetes (such as family history, increasing age and ethnic origin) are non-modifiable. However, other risk factors (such as being overweight or obese, having an adverse distribution of body fat and being physically inactive) are modifiable and need to be the focus of prevention strategies. The increase in Type 2 diabetes mirrors the increase in the proportion of people, including children and young people, who are either overweight or obese. Excessive body weight reduces the bodys ability to respond to insulin and is therefore a risk factor for Type 2 diabetes. Approximately one in five adults in England is now obese (defined as a body mass index6 >30 kg/m ) and two in five are overweight (defined2 as a body mass index 2530 kg/m ). Regular physical activity lowers the risk of developing Type 2 diabetes by increasing insulin sensitivity.

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