Another area worth investigating is whether the longitudinal use of decision support in different primary care practice settings (eg, private practices, community health centers, hospitals) improves patient outcomes. One approach is to never initiate DM therapy because there will be limited or no opportunity to provide suitable follow up. Patients felt more aware of and engaged in their own care through monitoring their glucose, sharing their glucose readings with the nurse case manager, and communicating with the nurse case manager via the secure e-mail system; uploading glucose readings and receiving feedback was easy. Currently no evidence-based literature exists to determine what level of glucose elevation warrants therapy. 8-month pilot test, natural experiment (n = 48). Using exploratory focus groups to inform the development of targeted COPD self-management education DVDs for rural patients. Diabetologia. Activate your 30 day free trialto continue reading. Diabetes Educ 2005;31(2):22534. Some organizations have already begun to do so. For example, Schillinger et al (15) found that weekly automated (prerecorded) tailored telephone calls from nurses were associated with improvements in interpersonal processes of care, physical activity and function, and slightly better metabolic outcomes (eg, HbA1c, blood pressure, cholesterol). Activate your 30 day free trialto continue reading. It appears that you have an ad-blocker running. Copyright 2021 VoiceThread LLC | WebDiabetes Mellitus and Cho Dis. Blood pressure; HbA1c levels; documentation and follow-up of goal setting; eye and foot examinations; medical residents receiving/reviewing/discussing registry reports; medical residents learning and demonstrating self-management support strategies. Fat people always develop type 2 diabetes eventually - this is not true. JAMA 2002;288(14):17759. We found evidence that CCM approaches have been effective in managing diabetes in US primary care settings. A low-cost decision support and information system based on the CCM is feasible in primary care practices, especially practices that lack sophisticated electronic information systems. WebTransforming media into collaborative spaces with video, voice, and text commenting. Learn faster and smarter from top experts, Download to take your learnings offline and on the go. 64% of patients with hypertension improved by at least 1 stage; 53% had a 1% reduction in HbA1c levels; 58% of patients with high LDL cholesterol improved by 1 risk group; mean arterial pressure, mean HbA1c, and mean LDL cholesterol showed significant improvements (. Only 1 study in our review (24) conducted weekly, skill-based learning sessions for racial/ethnic minority groups on healthful cooking modifications for traditional foods and snacks. Xfire video game news covers all the biggest daily gaming headlines. The volunteer physicians and specialists were available for consultation to manage challenging cases and questions (eg, difficult medication issues, questions directed to the physicians). S.Y. The authors recommend that each facility have a protocol in place for rapid detection, treatment, and secondary prevention of severe hypoglycemia, including intravenous (IV) dextrose and/or glucagon (which can be given subcutaneously (SQ), intramuscularly or IV). Nurses followed up with telephone calls to monitor progress toward goals. By whitelisting SlideShare on your ad-blocker, you are supporting our community of content creators. By accepting, you agree to the updated privacy policy. Clipping is a handy way to collect important slides you want to go back to later. First we reviewed the abstracts; 76 manuscripts met inclusion criteria, and 79 were excluded. Vaccinations, medications (statin use, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, aspirin), microalbuminuria. Weve updated our privacy policy so that we are compliant with changing global privacy regulations and to provide you with insight into the limited ways in which we use your data. The study selection process was conducted by 1 author (K.D.) Mean non-HDL cholesterol values and systolic and diastolic blood pressure improved in all groups, although the only statistically significant improvement was in diastolic blood pressure in the CCM group (. Training PCPs on evidence-based guidelines and methods for implementing CCM resulted in improved PCP adherence to clinical guidelines, including the American Diabetes Association (ADA) Standards of Care (1012,14,16,17) and Institute for Clinical Systems Improvement (ICSI) Clinical Guidelines for Hypertension, Diabetes, and Hyperlipidemia (18). Amor B, Harrison D, Rawler F. Assessment of the Clinical Outcome of a Symptom-Based Outpatient Hyperglycemia Protocol. Caruso LB, Clough-Gorr KM, Silliman RA. Diabetes is becoming more common in children and adolescents (32); Rapley and Davidson (33) have advocated for the adoption of CCM programs aimed at adolescent patients with diabetes to help bridge the gap between pediatric and adult care. The available rapid-acting insulin agents are sufficiently similar that all are reasonable choices. Team approach to care delivery used clinicians, nurses, and medical assistants. Circ Res. For all patients with a history of DM, it is logical and reasonable to check aBG level to detect significant hypoglycemia or hyperglycemia. Activate your 30 day free trialto unlock unlimited reading. Clinic nurse assisted patients with computer program to assess 10-year risks and focus on behavior change and goal-setting. Healthy Aging 2.0: the potential of new media and technology. The studies focused primarily on people aged 50 to 70 years. Used nurse case managers in the diabetes care delivery process; provided proactive follow-up based on patient needs, including the development of action plans to meet patient diabetes care goals; used information exchanged via secure e-mail communication between the nurse case manager and the patient to enhance patient care during office visits; integrated blood glucose trends and lifestyle information into ongoing patient care. In several studies (1012,14,1618), providing administrative support to train PCPs in implementing evidence-based care was associated with improved patient engagement that led to positive health outcomes. However, strategies for using community resources and developing policies were described in only 7 studies. This type of culturally appropriate self-management support was associated with a greater number of participants who had an HbA1c measurement of less than 7% and a fewer number of participants who had an HbA1c measurement of greater than 10% (24). Kitabchi AE, Umpierrez GE, Murphy MB, et al. Hyperinsulinemia enhances transcriptional activity of nuclear factor-kB induced by angiotensin II, hyperglycemia, and advanced glycosylation end products in vascular smooth muscle cells. Lifestyle school session included a model grocery store so participants could practice reading food labels, learn and apply skills to choose more healthful options during grocery shopping and when considering fast food options. J Clin Endocrinol Metab. Degree of structure of care alignment with CCM; process of care alignment with CCM; patient weekly self-care, quality of life, days spent in bed because of health problems; effect of diabetes on activities of daily living. Tokuda Y, Omata F, Tsugawa Y, et al. Finally, community-level partnerships pooled human and fiscal resources to provide diabetes management services (11,12,1618,20,24). WHO works with governments and partners across the Region to promote health, keep the world safe, and serve the vulnerable. Exercise is important for people with diabetes, as it is for everybody else. J Eval Clin Pract 2010;16(4):7006. These changes improved the quality of diabetes care and rates of eye examinations, and were associated with improved HbA1c levels, blood pressure, cholesterol, and weight (19,20). For more information about this message, please visit this page: CDC 24/7: Saving Lives. Participants had an established diagnosis of type 2 diabetes (age and sex were not reported). Click HbA1c, foot examinations, lipid panel, blood pressure, number of patients who had cardiovascular disease, diabetes, or both. Funding was obtained from local hospital foundation and parent hospital system. Layerthorpe, York (UK): York Publishing Services Ltd; 2009. Improving quality of care for urban older people with diabetes mellitus and cardiovascular disease. 3-year follow-up of clinical and behavioral improvements following a multifaceted diabetes care intervention: results of a randomized controlled trial. WebProfessional Case Study Writing Help: As Close to 100% As You Will Ever Be; Finding the 10/10 Perfect Cheap Paper Writing Services; 15 Qualities of the Best University Essay Writers; Expert Academic Essay Writers: Only the Best and Brightest Can Meet 100% of your Expectations; 3 Persuasion Methods for Justification Essays: Timely and Cheap Provider-perceived patient barriers to care; adherence to ADA standards of care; patient HbA1c, blood pressure, non-HDL cholesterol levels; height and weight; knowledge and empowerment levels; diabetic, lipid and blood pressure treatment intensification. One potential downside to treatment of acute hyperglycemia with insulin is the possibility of causing hypoglycemia 2 to 4 hours after the dose is given (duration of action of rapid-acting insulin is 4 hours). BG levels above 400 mg/dL are also significantly abnormal and the authors propose prompt consideration of short-term treatment, regardless of whether the elevation is due to stress hyperglycemia, underlying DM or new-onset or newly diagnosed DM. However, some participants found this communication system to be unstructured and preferred regular interaction (eg, face-to-face) with their nurse case manager; some participants found the smartphones to be frustrating because of technical difficulties associated with these unfamiliar technologies (23). For older populations of chronic disease patients (the age group sampled in most of the reviewed studies), training programs on the use of digital technologies for diabetes self-management may reduce the anxiety and barriers to access that may currently exist (23,34). and then repeated by the same author to ensure accurate selection; any discrepancies were analyzed and resolved on the basis of the inclusion and exclusion criteria. Interaction with the health care professional is an opportunity to recommend improving DM behaviors (avoidance of excess simple carbohydrates and calories) and adherence to pharmacologic therapy to decrease the future risk of diabetic microvascular complications, heart attack, or stroke. Providers should inquire about the timing of last insulin administration and dose and type of insulin being used and that information should be factored in to treatment decisions. If significant hypoglycemia is detected (<70 mg/dL), it should be promptly corrected (usually with administration of 15 g of a rapidly available oral carbohydrate) and steps taken to avoid recurrent hypoglycemia prior to discharge. Future system-level CCM reorganizations should create clear access points for providers to intervene with patients who are at risk for diabetes complications. 2001; 24(1): 131-153. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. The rate of fall of BG can be factored into the decision about whether a repeat insulin bolus (or boluses) is needed and how much to provide. Penn State Institute for Diabetes and Obesity patient registry system was used to identify patients with uncontrolled diabetes (HbA1c >8.5), hypertension (blood pressure >140/90 mm Hg), or hyperlipidemia (low-density lipoprotein cholesterol >130 mg/dL). We've updated our privacy policy. Kosiborod M, Inzucchi SE, Spertus JA, et al. We've encountered a problem, please try again. Assessment Of Pancreatic Hormones In Diabetes Mellitus & Non-diabetes Mellitu 14. a case study on diabetes mellitus type 1 with diabetic ketoacidosis cp in Case Presentation: Hypertension (A case on refusal of Evidence Based Medicine), Diabetes mellitus - a case presentation for SPM, R.C patel institute of pharmacutical education and research, shirpur. Chronic diseases and health promotion. Detection of Undiagnosed Diabetes and Prediabetes States in High-Risk Emergency Depertment Patients. professional development Modest stress-induced hyperglycemia is common in pediatric ERs but BG levels above 300 mg/dL are considered unusual and may be a marker of severity of illness and poorer outcome.20 Underlying DM may not be present in the majority of cases. In a recent study at an inner-city hospital in Detroit, HbA1c levels were checked on all patients who presented to the ER for any reason. Further, this risk can be avoided by documenting that advice has been given to patients to follow up with the responsible physician in a reasonably short period of time. B.V CON , Pune. design discussions Click here to review the details. Feel safe whenever you are placing an order with us. The Chronic Care Model (CCM) uses a systematic approach to restructuring medical care to create partnerships between health systems and communities. Implementing the chronic care model in an academic setting: a residents perspective. Management of children is another special case. WebAbout Our Coalition. Diabetes Care 2012;35(Suppl 1):S1163. It is also noteworthy that none of the reviewed studies addressed the needs of pediatric patients diagnosed with either type 1 or type 2 diabetes. Rockwood Clinic Foundation mission was refocused toward efforts to support and promote research in new systems of health care delivery. Extreme Stress Hyperglycemia During Acute Illness in a Pediatric Emergency Department. Patients led the discussion according to individual needs, and the CDE facilitated the discussion to include ADAs 10 content areas. Stellefson M, Chaney B, Chaney D. The digital divide in health education: myth or reality? These patients require referral to an ER for further management and likely hospital admission. We now know that stress hyperglycemia, left untreated, has been associated with longer hospital stays, higher rates of ICU admission, greater need for rehabilitation services at time of discharge, and higher mortality rates.4, The link between hyperglycemia and adverse outcomes is multifactorial. General, family, and internal medicine practices (n = 24) in Pittsburgh, Pennsylvania. The authors recommend a very low threshold for hospital admission for children with known type 1 DM (or type 2 DM) with good support and/or self-management skills and suitable short-term follow up may not require hospital admission simply for hyperglycemia, as long as diabetic ketoacidosis, a metabolic urgency or dehydration is not present. The SlideShare family just got bigger. conversational practice Used ADA diabetes education content areas. We therefore recommend checking a basic chemistry panel that includes sodium, potassium, urea, and creatinine in all patients with marked hyperglycemia (>400 mg/dL), especially those taking diuretics, patients with evidence of volume depletion and those with a history of renal dysfunction. In several studies, organizational leaders in health care systems initiated system-level reorganizations that facilitated more comprehensive and coordinated diabetes care. However, assuming that a patient does not fulfill criteria for hospital admission and there is clear evidence of new onset or newly diagnosed type 2 DM, then initiating treatment with clear documentation of a plan for suitable short-term follow up is a consideration. STROKE. The PCP then answered yes or no if the message was helpful and if it was used in developing patient plans. Glucocorticoid induced insulin resistance impairs basal but not glucose entrained high-frequency insulin pulsatility in humans. The Innovative Care for Chronic Conditions (ICCC) model espoused by the World Health Organization (33,37) is comparable to the Expanded Chronic Care Model proposed by Barr and colleagues (7); it introduces prevention efforts, social determinants of health, and enhanced community participation as core components of chronic disease care. Features such songs as "White Knuckle Ride", "One Foot on The Pedal", and "You Gotta Wanna To address barriers to care, such as poor diabetes knowledge, low awareness of educational service accessibility, and lack of psychosocial support (10,26), PCPs streamlined DSME services by offering diabetes days and planned visits exclusively for people with diabetes (1012,1421,24). Physicians and their patients were randomized to the control or intervention group (clustered randomization). Cord Prolapse- 01/ 1764 Deliveries Rupture Uterus- 00/ 1764 Deliveries Compound Presentation- 05/1764 Deliveries 78. We, therefore, propose involving patients in the decision whether to provide insulin and/or IV hydration. It has the advantage of correlating with pathogenicity and clinical manifestations, which differ among types. Planned Visit Worksheet was used to ensure evidence-based diabetes care aspects were addressed during visits. More public-private partnerships need to be developed between providers and community organizations to address barriers to care and explore culturally appropriate community-based services (eg, cooking classes, exercise programs, nutrition counseling, self-monitoring assistance) for underserved populations and neighborhoods. Qualitative evaluation of a mobile phone and web-based collaborative care intervention for patients with type 2 diabetes. If the correction factor for glucose lowering is known to the patient, an urgent care provider can use that correction factor as a reference point for dosing. Chronic care model and shared care in diabetes: randomized trial of an electronic decision support system. Microsoft pleaded for its deal on the day of the Phase 2 decision last month, but now the gloves are well and truly off. Patients with BG levels above 400 mg/dL or systolic blood pressure less than 100 may be at higher risk of DKA. Released in 1996 and featuring songs from Lynyrd Skynyrd, Waylon Jennings, Alabama, Tanya Tucker, and Hank Williams Jr, among others, this 32-minute, 11-song album was an album ode to NASCAR by some of country's biggest stars. The risk should be minimized by using a suitable protocol with BG monitoring (using meters appropriate for the urgent care setting). Gerstein HC, Miller ME, __ et al. Enjoy access to millions of ebooks, audiobooks, magazines, and more from Scribd. 1997; 314(7093): 1512-1515. NICE study investigators, Finfer S, Chitlock DR, et al. Diabetes Public Health Resource; 2012. http://www.cdc.gov/diabetes/consumer/groups.htm. Each resident practiced a planned visit with a patient. More personalized, patient-centered interactions (eg. The goal is to confirm that the patients hyperglycemia has resolved, and if not, to provide information to allow suitable follow up of the newly diagnosed DM. Midico-legally an argument can be made for not checking a BG level in patients with preexisting DM so as to avoid the risk of the urgent care facility becoming directly responsible for glucose-related issues in the event of detection of marked hyperglycemia that could be transient or preexisting. We determined which of the 6 CCM components had been applied to each intervention and how the component(s) had been applied. Additional challenges are that many patients lack health insurance and may not have an identifiable primary care physician. Impact of patient level factors on the improvement of the ABCs of diabetes. Only 6 of 16 studies (11,12,1618,20) implemented all 6 CCM components (Table 2). Weve updated our privacy policy so that we are compliant with changing global privacy regulations and to provide you with insight into the limited ways in which we use your data. CCM group mean (SD) age, 69.0 (12.3) y; 53.3% male, 20% nonwhite. Coca A, Francis MD. 76 female patients; mean age, 51.9 y; 47.7% Hispanic. We also recommend checking BG levels in any patient in whom hyperglycemia is suspected (major stress, symptoms of hyperglycemia, history of poorly controlled DM, possible new-onset or newly detected DM) or hypoglycemia. WebGrow your business on your terms with Mailchimp's All-In-One marketing, automation & email marketing platform. Anthony J. Intensive versus Conventional Glucose Control in Critically Ill Patients. Two studies (19,20) revised the health care system to redefine health care team roles (eg, nurses, instead of PCPs, became responsible for conducting foot examinations). If insulin is likely to be needed, then a patient likely should be hospitalized. We conducted a literature review by using the Cochrane database of systematic reviews, CINAHL, and Health Source: Nursing/Academic Edition and the following search terms: chronic care model (and) diabet*. We included articles published between January 1999 and October 2011. Diabetes Passport served as patients personal record of blood pressure, HbA1c levels, weight, and cholesterol, along with their goals and plans. Protecting People., National Center for Chronic Disease Prevention and Health Promotion. Patients may need to be involved in the deciding whether to check a BG level and/or whether to give insulin if marked hyperglycemia is detected (> 400 mg/dL). Mortality and morbidity from common conditions needing surgery have grown in the world's poorest regions, both in real terms and relative to other health gains. Patients reported comfort with location and ease of approaching CDEs. Offering DSME in primary care settings, rather than solely hospital settings, enhances the reach of such programs in a more intimate, socially supportive venue. Comprehensive models of care, such as the original Chronic Care Model (CCM) (4,5), advocate for evidence-based health care system changes that meet the needs of growing numbers of people who have chronic disease. Diabetes Care 2006;29(4):8117. It appears that you have an ad-blocker running. With the increased use of urgent care centers rather than ERs or routine visits to a primary care physician for various ailments, hyperglycemia is commonly encountered in both the diabetic and non-diabetic populations. Barriers to Diabetes Care survey, Diabetes Attitude Scale, Diabetes Empowerment Scale, Diabetes Knowledge Test, and the Diabetes Self-Management Program of the University of Pittsburgh Medical Center Health System Initial Assessment. Participants showed a decrease in HbAlc levels (mean HbA1c decreased from 8.6 to 8.0) after an average of 20.6 months of participation in self-management activities. Diabetes Educ 2006;32(2):25360. The ICCC has a larger focus on supporting positive policy environments (ie, partnerships, legislative frameworks, human resource allocation, leadership, and financing) in community and health care organizations (33,37). JAMA. Am J Health Educ 2008;39(2):10612. IV hydration is required for all patients with a glucose levels > 600 with symptoms, signs or laboratory features of significant dehydration. Weiss SL, Alexander J, Agus MS. Implementing the chronic care model for improvements in diabetes care and education in a rural primary care practice. Inclusion criteria specified that studies 1) be published after the formal inception of the original CCM (1999) (5); 2) use the original CCM (4,5) instead of the expanded CCM (7); and 3) describe CCM-based interventions to manage and treat diabetes in US primary care settings. We've encountered a problem, please try again. 1-year change in self-management behavior. Tachycardia may be present due to dehydration or associated conditions (infection, electrolyte disturbance). 201; 26: 626-632. Management of acute hyperglycemia emergencies is beyond the scope of this article.21 However, it is very important in the urgent care arena to recognize patients with hyperglycemia metabolic emergencies, that is, DKA and non-ketotic hyperosmolar syndrome. This Friday, were taking a look at Microsoft and Sonys increasingly bitter feud over Call of Duty and whether U.K. regulators are leaning toward torpedoing the Activision Blizzard deal. This information was used to create single-line, positively framed messages (information was presented as gains, not losses), which were shown to elicit a better response from physicians. Insulin is the logical choice for acute management. WebA precise comparison of the state-of-the-art (SoA) solutions of electronically controllable inductance simulators is provided in Table 1.The following conclusions can be made: (a) only a limited number of complex solutions (example in []) allow the cancellation (neither electronic cancellation) of serial losses, and (b) voltage adjustment of the value of Problem-based learning sessions were used to demonstrate implementation of guidelines into a plan of care. We've updated our privacy policy. Innovative care for chronic conditions: building blocks for action: global report (document no. Presentation on : Accessed October 7, 2012. IV insulin has rapid onset of action and shorter total duration versus SQ rapid-acting and certainly versus SQ regular insulin. A discussion of possible behavior changes followed, concluding with agreed-upon goals. Centers for Disease Control and Prevention. Other culturally tailored non-CCM interventions (29) have demonstrated larger absolute reductions in HbA1c than nontailored interventions. You can read the details below. We've updated our privacy policy. The authors propose aiming for a glucose target between 120 and 180 mg/dL. Hospital and PCP collaborations within the community, such as partnerships between the University of Pittsburgh Medical Center and western Pennsylvania community hospitals and PCP offices (12), provided greater access to funding, information systems, and administrative support for CCM implementation (11,12,16,17). SEMINAR Offered chronic disease self-management classes to teach patients behavioral goal setting and strategies to overcome barriers and promote peer support. However, hypoglycemia can occur with sulfonylureas, therefore, patient education is required about detection and management of hypoglycemia. Abbreviations: CDE, certified diabetes educator; ADA, American Diabetes Association; PCP, primary care physician; DSME, diabetes self-management education.a The 6 components of the CCM are 1) health system organization of health care, 2) self-management support, 3) decision support, 4) delivery system design, 5) clinical information systems, and 6) community resources and policies. (dr.adnan hamawandi), .nephrotic syndrome- B.Sc. Factors requiring consideration of lower insulin dosing include low body weight, known insulin sensitivity, and underlying renal and liver disease. Urgent message: Acute hyperglycemia is a common and potentially challenging problem in urgent care that deserves to be managed appropriately based on the best available evidence and suitable consideration of the associated complexities. We searched for articles published between January 1999 and October 2011. Free access to premium services like Tuneln, Mubi and more. Diabetologia. We recommend a treatment goal of 150 mg/dL (120-180 mg/dL). According to The American Diabetes Association, an HbA1c level (obtained from a reference laboratory) 6.5% indicates a diagnosis of DM.19. Free access to premium services like Tuneln, Mubi and more. Future studies on diabetes self-management support within the broader CCM framework should attempt to refine the use of information and communications technologies to empower, engage, and educate patients (36). Signs of dehydration may be present, such as orthostatic fall in blood pressure and tachycardia. 2011; 17: 370-375. Diabetes health disparities: a systematic review of health care interventions. DOI 10.1007/s00125-012-2534-0. A meta-analysis of interventions to improve care for chronic illnesses. Introduction Lyles CR, Harris LT, Le T, Flowers J, Tufano J, Britt D, et al. Nephritic syndrome by Dukundane Alexandre, pediatrics.Glomerulonephritis. Sustained outcomes in quality of well-being, self-monitoring of blood glucose. Another consideration is whether an urgent care facility should provide a prescription for blood glucose monitoring (or even provide a meter sample and a short supply of testing strips, if available to the facility). Number of ADA-recognized programs grew from 3 to 21 through decision support. One study (12) even noted that providing DSME programs in PCP offices instead of hospital settings resulted in a 2- to 3-fold increase in the number of patients reached with diabetes education. It appears that you have an ad-blocker running. Other models have sought to improve the community resources and policies component of the CCM. We then reviewed the full articles; 43 articles were retained, and 33 were excluded. World Health Organization; 2002. Individual patient reports were also provided to health care teams for reviewing clinical trends (eg, HbA1c, blood pressure, lipids) and initiating clinical responses to laboratory results (eg, medication adjustments) (9,10,20,23). The Medical Archival Retrieval System allowed for reimbursement and usability monitoring. rich assessment Audit of Diabetes Dependent Quality of Life survey, Problem Areas in Diabetes scale, Diabetes Treatment Satisfaction Questionnaire, Summary of Diabetes Care Activities, and the Provider Satisfaction Inventory. If marked hyperglycemia (> 400 mg/dL) is detected, even if not treated acutely, this should prompt a chemistry panel to evaluate for metabolic decompensation and a recommendation for the patient to follow up with his or her physician. Practical clinical trial with 3 arms: interactive weekly automated telephone self-management support with nurse follow-up (ATSM), group medical visits with physician and health educator facilitation (GMV), and usual care; random assignment to groups (n = 339). Assimilating clinical information systems into user-friendly, portable digital technologies (ie, smartphones, iPads) may enable patients and providers to view and respond to laboratory results more regularly. A suggested protocol for marked hyperglycemia (above 400 mg/dL) in patients without known insulin-deficient DM such as type 2 DM is to provide a SQ bolus of rapid-acting insulin, starting with 0.1 to 0.15 units/kg. Standardized Glycemic Management and Perioperative Glycemic Outcomes in Patients with diabetes mellitus who undergo same-day surgery. However, half of the patients found the use of smartphones to be frustrating (unfamiliar technology). Centre for Reviews and Dissemination. Curr Diab Rep. 2012; 12(1): 101-107. 1998; 21: 246-249. It may be prudent to check electrolyte levels in patients treated with insulin prior to discharge. However, insulin remain the medication of choice if acute treatment is needed. Mean (SD) age, 51 (12) y; 59% male, 42% African American. Mean age, 58 y; 57% female; 39% Hispanic. CDE worked with staff to schedule DSME; CDE served as a clinical resource; PCPs hosted diabetes days; PCPs made direct referrals to CDEs. HbA1c improvements observed at 1-year follow-up were sustained in 8 of 12 participants in CCM group at 3-year follow-up, whereas the provider-educationonly group and usual-care group remained constant from baseline. Umpierrez GU, Hellman R, Korytskowski MT, et al. Diabetes Care. Modified Diabetes Care Profile; World Health Organization (Ten) Quality of Well-Being Index. Contraindications include risk of lactic acidosis, such as in patients with renal insufficiency, liver disease, advanced heart failure, alcohol abuse and exposure within 48 hours to IV computed tomography contrast material. ATSM seems to be a more effective communication method for self-management support than monthly GMV for improving behavior and quality of life for patients with poorly controlled diabetes. Health system reorganization also helped to establish diabetes self-management training programs (12,16,17) that identified and intervened with patients at risk for developing complications (17) and improved clinical and behavioral outcomes (12,16). Seven studies (11,12,1618,20,24) specified strategies for using community resources and forming public policy. Effects of Intensive Glucose Lowering in Type 2 Diabetes (The Action to Control Cardiovascular Risk in Diabetes Study Group (ACCORD). Study settings included academic-affiliated primary care practices (10,1214,21,23), private practices (11,16,17,20), community health centers (15,24), safety net clinics (18,19,22), and a hospital (9). University of Washington general internal medicine clinic, Seattle, Washington. Insulin-treated patients will often use rapid-acting insulin to treat hyperglycemia, so it is logical to provide similar therapy while in an urgent care center. The sum of these CCM component parts are purported to create more effective health care delivery systems that institute mechanisms for decision support, link health care systems to community resources and policies, deliver comprehensive self-management support services for patients, and operate and manage patient-centered clinical information systems. Patient with more marked hyperglycemia may have potassium shifts with insulin therapy (and may have underlying potassium depletion). Part 2 of this article will discuss screening for diabetes, including guidelines for estimated average glucose and the role of oral agents in urgent care. no-schedule office hours Providers need to place the level in the appropriate context (probable stress hyperglycemia, known type 2 DM, known insulin-treated or type 1 DM, known alternative cause of DM [steroids, post pancreatic surgery, chronic pancreatitis, etc. Logistic regression for binary outcome measures (eg, success in meeting HbA1c, blood pressure, and LDL cholesterol goals); generalized estimating equations for longitudinal data; repeated measures analysis of variance for continuous outcomes (eg, HbA1c, systolic blood pressure, lipids). Electronic registry of patients with diabetes tracked care and outcomes. Secure, password-protected patient registry was created on Microsoft Excel and managed by a registered nurse. DOI: What level of glucose elevation in the urgent care setting, should be treated, why, and to what level? WebManagement Business and Economics Marketing Case Study +59. In 2010, the Centers for Disease Control and Prevention reported that 25.6 million, or 11.3%, of US adults aged 20 or older had diagnosed or undiagnosed diabetes (1). If a patient who likely need insulin treatment refused hospital admission, then prescribing insulin without a mechanism for follow up with the prescribing provider or facility would likely present an unwarranted medico-legal risk. Diabetes Metab Syndr Obes. WebBright light therapy has been found effective in manipulating melatonin production and the timing, effectively re-setting the circadian rhythm "body clock", and exposure to light also helps increase serotonin production.Bright light therapy is just like it sounds - exposure to intense levels of light!Green or green-blue light to be specific.Light therapy, also known as PICK, MD, CDE, DAVID L. PICK, MD, FAAFP, and LOWELL R. SCHMELTZ, MD Hyperglycemia is common in acute care settings such as emergency rooms (ERs) or urgent care centers. Activate your 30 day free trialto unlock unlimited reading. Curr Opin Cfrit Care. Hall AK, Stellefson M, Bernhardt JM. Patients from Vermont and New York primary care practices in the Vermont Diabetes Information System (VDIS). Stroebel RJ, Gloor B, Freytag S, Riegert-Johnson D, Smith SA, Huschka T, et al. Delivery system design was identified as an important strategy for integrating DSME into primary care settings through addressing patient barriers to care such as accessibility to DSME and availability of staff to assist with diabetes care (10). You can read the details below. However, it can also be the first presentation of type 1 diabetes. Each issue contains a mix of peer-reviewed clinical and practice management articles that address the distinct clinical and practice management needs of those who are working in todays busy urgent care centers. We then qualitatively assessed the outcomes of each component that was applied in each study. sales and marketing, replace text-only discussions Patients communicated with a nurse case manager on their diabetes care via a secure e-mail connection. Collaborations were formed between the University of Pittsburgh, community leaders, physicians, community hospital foundation, and Lions clubs. ANTHONY J. Most cases of ketoacidosis occur in people with established type 1 diabetes, especially if they have another illness or miss insulin doses. In conclusion, our study provides evidence that CCM is effective in improving the health of people who have diabetes and receive care in primary care settings. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. The open side of a pillow case should be away from the main door of the ward. CCM group mean (SD) age, 69.7 (10.7) y; 50% male; 13% nonwhite; 50% less than a high school diploma; 44% income <$20,000/year. CCM intervention group that received virtual consultation: median duration of diabetes, 4 y (range, 043 y); median age, 62 y (range, 2292 y); median BMI, 33 (range, 1866); median HbA1c, 7.3 (range, 5.215.1). We propose checking BG levels in all patients with a history of DM, especially those on pharmacologic therapy, because of the minimal downside to the practice in individuals with DM in whom the check confirms a reasonable BG level confirmed, the possibility of detecting significant hypoglycemia or hyperglycemia with reasonable frequency, and the weakness of the legal argument for not checking BG levels. Adapting the chronic care model to treat chronic illness at a free medical clinic. Many studies (9,10,12,14,18,20, 21,23,24) used disease registries and electronic medical records to establish patient goals, monitor patient progress, and determine lapses in patient care. For example, ADA standards require that people with diabetes receive DSME to optimize metabolic control, prevent and manage complications, and maximize quality of life in a cost-effective manner (25). At the other extreme, in an insulin-resistant patient, BG levels may fall 5 to 10 mg/dL per unit or rapid-acting insulin can be used. Means for CCM, provider-educationonly, and usual-care groups combined: mean (SD) age, 67.6 (9.4) y; 50.4% male; 8.6% nonwhite. Participants and their family members met with team members for five 2-hour group sessions biweekly. These assessments could enable health care administrators and professionals to determine how CCM could become further integrated into primary health care initiatives in diabetes. professional development, student presentations CCM is used as the framework; laboratories provide daily data feeds; algorithms provide automatic test interpretation; fax and mail are used for providers not easily reached by electronic networks; reports are formatted for accessibility and usability by patients and providers. Another factor is patient waiting time. Obstetrical Emergency in details this plan of clinical teaching. Problem-based learning sessions were held for PCPs, led by an endocrinologist using diabetes management questions. It appears that you have an ad-blocker running. You can read the details below. Case management, evidence-based care, cultural competency, improved provider interactions. Challenges for tailored messaging in health education. Abruptio placenta- Define, cause, sign and symptoms, Risk Factors, Incidence, Breathlessness in pregnancy ---respiratory resasons, Resuscitation in pregnancy dr.krushna patel, Medical management of Post Partum Haemorrhage, Anesthesia for ANTEPARTUM HAEMORHHAGE (APH), Preeclampsia in pregnancy etiopathogenesis and management, Anaesthetic management of obstetric emergencies, No public clipboards found for this slide. Accessed June 12, 2012. The objective of this study was to determine how CCM has been applied in US primary care settings to provide care for people who have diabetes and also to describe outcomes of CCM implementation. Above this BG level there can be polyuria followed by osmotic shifts and electrolyte disturbances as BG levels rise further. Enough of the problem: a review of time for health care transition solutions for young adults with a chronic illness. Groups especially affected. We identified 155 studies (Figure) and reviewed them in 3 steps. Management of Hyperglycemia Crises in Patients with Diabetes. J Clin Nurs 2010;19(3-4):31323. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2007. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf. Abbreviations: SD, standard deviation; ADA, American Diabetes Association; HbA1c, hemoglobin A1c; DSME, diabetes self-management education; CDE, certified diabetes educator; HDL, high-density lipoprotein; PCPs, primary care providers; BMI, body mass index; LDL, low-density lipoprotein; CI, confidence interval. Translating the chronic care model into the community: results from a randomized controlled trial of a multifaceted diabetes care intervention. Met ADA recognition qualifications for diabetes educator support in PCP offices. WebBrowse our listings to find jobs in Germany for expats, including jobs for English speakers or those in your native language. Reorganized care can also support better training programs for patients to help them self-manage diabetes. Registry was used to identify patients who had not been seen in 6 months or had HbA1c levels >8%. Prop 30 is supported by a coalition including CalFire Firefighters, the American Lung Association, environmental organizations, electrical workers and businesses that want to improve Californias air quality by fighting and preventing wildfires and reducing air pollution from vehicles. Hollingdal M, Juhl CB, Dall E, et al. extracted the data. Organizational leaders in health care systems initiated system-level reorganizations that improved the coordination of diabetes care. DePaul University does not discriminate on the basis of race, color, ethnicity, religion, sex, gender, gender identity, sexual orientation, national origin, age, marital status, pregnancy, parental status, family relationship status, physical or mental disability, military status, genetic information or other status protected Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline. GPS coordinates of the accommodation Latitude 438'25"N BANDOL, T2 of 36 m2 for 3 people max, in a villa with garden and swimming pool to be shared with the owners, 5 mins from the coastal path. The same author (K.D.) Trained clinicians to treat patients to target blood glucose control and cardiovascular risk factors. However, it is important to determine the combination of components that will likely produce optimal patient and provider outcomes. Health Aff (Millwood) 2001;20(6):6478. A 2- to 3-fold greater proportion of patients reached when DSME was available at primary care practices compared to hospital-based programs. Click here to review the details. Laboratory results, participation data from registry. Only 1 person selected the studies for inclusion in our review. DM is often undiagnosed and has serious long-term complications, so it is reasonable to consider near universal BG testing in adults. CCM was developed (4,5) to provide patients with self-management skills and tracking systems. Patients with Type 1 DM who have taken basal insulin within 24 hours, those using an insulin pump or who have recently taken a bolus of rapidly acting insulin likely will require frequent blood glucose monitoring, too. Now customize the name of a clipboard to store your clips. NURSING NEPHROTIC SYNDROME DR. ABHAY MANGE 2. Medical Archival Retrieval System was used to track reimbursement, DSME service rates, and HbA1c levels. word file, Faculty of Medicine,Zagazig University,EGYPT. Classification, Pathophysiology and management of Brain Stroke for Pharm.D (P Stroke I Incidence, Types, Causes, Risk Factors & Management - Dr Rohit Bhaskar, Neurology 9th vascular diseases of the nervous system, Brain stroke by Roel Tolentino Makati Philippines, Approach to a patient with stroke - Pathophysiology of stroke, Mrs. Duru Onyinye Ann Ph.D Power Point i.pptx, No public clipboards found for this slide. Medications were reviewed in group setting; discussion focused on adherence. 1. Study produced mixed results. support UDL principles The SlideShare family just got bigger. Initiation of a sulfonylurea such as glipizide or glimepiride is also a consideration. (VADT). BG monitoring every 1 to 4 hours may be required for patients with prolonged stays in urgent care facilities who are on medications with risk of causing hypoglycemia, such as insulin or sulfonylurea. There is a growing literature on screening for diabetes or prediabetes in the acute care setting. Process of diabetes care, metabolic and vascular risk factor control with a 10-year estimated risk of cardiovascular disease; cost of care; participants functional health status. WebRemarkable gains have been made in global health in the past 25 years, but progress has not been uniform. Endocrinologists provided the telemedicine intervention, delivering these tailored messages to the primary care team for review 48 hours before the patients next scheduled visit. Looks like youve clipped this slide to already. STROKE S Diabetes days scheduled; on these days, a CDE was present in PCP offices. Ginde AA, Cagliero E, Nathan DM, Carnargo CA Jr. Point-of-care Glucose and Hemoglobin A1C in Emergency Department Patients without Known Diabetes: Implications for Opportunistic Screening. Our review supports the idea that DSME improves psychosocial and clinical outcomes. Use of long-acting insulin such as NPH, detemir (Levimir, Novo, Nordisk), glargine (Lantus, Sanofi) will likely be done les soften and selectively. Clipping is a handy way to collect important slides you want to go back to later. Random BG levels are also appropriate if the medical history raises a suspicion of new-onset or undiagnosed DM (classic symptoms such as polyuria, polydipsia, rapid weight loss, blurred vision, suspicious infections (significant skin yeast infections, abscess, anaerobic infections, foot infections, hidradenitis suppurativa), and patients present with severe illness (increased likelihood of at least stress-induced hyperglycemia and may be a marker of worse outcomes). Engaging the governing boards of health care systems resulted in support for institutionalizing the CCM approach (18,22), which was associated with HbA1c reductions of at least 1% during 12 months (18,22) and improved foot care (22). Walk-in urgent care clinic for uninsured patients. Now customize the name of a clipboard to store your clips. Contemp Clin Trials 2009;30(4):36674. If needed, the insulin can be rebolused, with or without dose adjustment based on the response. Benedetti R, Flock B, Pedersen S, Ahern M. Improved clinical outcomes for fee-for-service physician practices participating in a diabetes care collaborative. professional development Facilitators, such as Certified Diabetes Educators (CDEs) or nurses, provided instruction on various topics, such as medication compliance, goal setting, foot care, and interpretation of laboratory results (1012,1417,20,24). The 16 studies included various study designs, including 9 randomized controlled trials, and settings, including academic-affiliated primary care practices and private practices. CDE provided individual diabetes counseling, including nutritional counseling. Personal barriers to diabetes care: lessons from a multi-ethnic community in New Zealand. Manag Care Q 1999;7(3):5666. WebMaria Montessori - Free download as Word Doc (.doc), PDF File (.pdf), Text File (.txt) or read online for free. Patients treated with insulin may have knowledge of an adjustment algorithm for management of hyperglycemia. Diabetes Educ 2007;33(Suppl 6):132S8S. University of Pittsburgh Medical Center provided educators with access to funding, information systems, PCPs, and hospital administration. WHO/NMC/CCH/0201). Easy to use - start for free! Pregnant patients are another special category of patients who present to urgent care with hyperglycemia. We did not conduct a meta-analysis because we did not have access to primary data, and the variability in study design did not allow us to pool data. Long-acting insulin preparations are used by patients with type 1 and insulin-deficient type 2 DM to provide a low level of background insulin to suppress hepatic gluconeogenesis and prevent hyperglycemia due to excess endogenous glucose production. Diabetes days were organized: on these days, CDEs were in PCP offices for routine office visits and DSME. Created patient registry to track clinical measures and generate patient performance reports for patients and providers. In several studies (1012,14,1618), this training was associated with improved diabetes knowledge among patients and improved levels of HbA1c and high-density lipoprotein (HDL) cholesterol. Author Affiliations: Michael Stellefson, Christine Stopka, University of Florida, Gainesville, Florida. BG level at or above 600 mg/dL are markedly abnormal, often associated with dehydration and metabolic emergencies, and often require electrolyte measurement, IV hydration, insulin administration, more than brief observation and possibly require hospital admission. PRESENTATION ON: The Western Pacific Region is home to almost 1.9 billion people across 37 countries and areas in the Asia Pacific. Provider adherence to ADA guidelines improved significantly: lipid profile and urinalysis (. Natural experiment with comparison group; 11 participating providers had 698 patients; 19 nonparticipating providers had 1,300 patients. To get feedback from the supervisors and friends for further improvement. L Prospective single cohort study (n = 1,098). 1. A reasonable starting quantity would be sufficient for 1 week. Pediatr Emerg Care. McNemar test for dichotomous data, Wilcoxon signed rank test for ordinal data, and paired, Mean change in lowering HbA1c levels was significant (. However, any patient with blood glucose elevations sufficiently elevated to require acute treatment will require suitable short-term follow up after discharge. Implemented patient goal-setting strategies and group visits. Figure. Liebman J, Heffernan D, Sarvela P. Establishing diabetes self-management in a community health center serving low-income Latinos. As noted above, a normal fasting BG level is less than 100 mg/dL in a non-diabetic individual. Weve updated our privacy policy so that we are compliant with changing global privacy regulations and to provide you with insight into the limited ways in which we use your data. WebDiabetic ketoacidosis. Elevated admission glucose and mortality in elderly patients hospitalized with heart failure. ], probable new onset or undiagnosed DM (type 2, type 1 or other) or confirmed new-onset or newly dehydration or electrolyte disturbance); identify patients at high risk for adverse outcomes (marked stress hyperglycemia, major co-morbid event (stroke, myocardial infarction, severe infection) and potentially identify high-risk patients with poorly controlled DM or new-onset DM who warrant arrangements for appropriate follow up. Each database was separately searched. collaborate with clients Future studies should investigate how different derivations of CCM components contribute to changes in diabetes care within primary care settings. We conducted our analysis in October 2011. An HbA1c level may be helpful in this regard. Interactive feedback using the Web-based My Diabetes Daily Diary self-management tool focused on nutrition, medications, and exercise. no-schedule meetings Suggested citation for this article: Stellefson M, Dipnarine K, Stopka C. The Chronic Care Model and Diabetes Management in US Primary Care Settings: A Systematic Review. BELOW ARE SOME DIABETES MYTHS: People with diabetes should not exercise not true!! Future studies should use the multiple-rater approach for study selection and data extraction as outlined by the Centre for Reviews and Dissemination systematic review guidelines (8). Enjoy access to millions of ebooks, audiobooks, magazines, and more from Scribd. There is a growing literature on screening for diabetes or prediabetes in the acute care setting.24-27 Urgent care facilities may be well suited to perform diabetes screening, provide basic diabetes education (such as suitable referrals for longitudinal care. E-mail: safe and accountable, Terms of Use | Forward linear regression, general linear regression. Web27. Patients who are stable need to be involved in the decision about whether to treat hyperglycemia with IV hydration and/or insulin and the associated increased time likely to be spent in the facility. Murad MH, et al. The authors are not aware of any guidelines specific to hyperglycemia management in urgent care, based on a Medline search using the MeSH terms (Diabetes or hyperglycemia and Urgent Care.) Goals of therapy in an insulin-treated patient are exclusion of a metabolic emergency; detection, treatment or prevention of marked hyperglycemia or hypoglycemia; and possibly detection of patients with poor control to encourage suitable follow up after discharge. Position station of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). PCPs completed routine examination and assessed complications during each visit. This work was supported in part by the National Institutes for Health National Center for Advancing Translational Sciences Clinical and Translational Science Award to the University of Florida no. However, marked hyperglycemia in a child could reflect underlying type 1 DM. Conflicts of Interest: David L. Pick has no conflicts of interest to report. Diagnostic records /certified fixed orthodontic courses by Indian dental acad Case Report: Heparin Induced Thrombocytopenia (HIT), PTERYGOID HAMULUS SYNDROME- A CASE REPORT, Planning,implementation and evaluation of education program on diabetes, Symptoms of Pre-Diabetes and Diabetes Prevention Tips, Eating Disorders and Type 1 Diabetes Mellitus, Dr Vivek Baliga - Chronic Disease Management In Heart Failure And Diabetes, Alphabet strategy for Diabetes Care for those Living with Diabetes, From renal failure to renal transplant updated oct 13. NEPHROTIC SYNDROME BMJ. The CCM group had the largest decrease in HbA1c values (0.6%. In the non-diabetic population of 5,372 individuals, 7% had an elevated HbA1c of 6.5% indicating a new diagnosis of diabetes. CCM comprises 6 components that are hypothesized to affect functional and clinical outcomes associated with disease management. Int J Telemed Appl 2010;2010:450418. Presented By:- Future research on integration of CCM into primary care settings for diabetes management should measure diabetes process indicators, such as self-efficacy for disease management and clinical decision making. Rapid-acting insulin analogs (glulisine [Apidra, Sanofi-Aventis U.S. LLCJ]), insulin aspart (NovoLog, Novo Nordisk Pharmaceuticals Inc.) and insulin lispro (Humalog, Eli Lilly and Co.) have superior insulin kinestics to regular insulin. As recommended by the Centre for Reviews and Dissemination systematic review guidelines (8), we created the following categories to systematically assess the 16 studies and gain an understanding of the methods used and the outcomes associated with CCM application: study design, sample size, setting, participant demographics, primary and secondary outcomes measured, data collection instruments used, statistical tests used, and major findings. Rapley P, Davidson PM. Classification of cryoglobulinemia is based on a system developed more than 40 years ago. Phenomenology to analyze participants narratives; thematic coding; Atlas.ti version 5.2 used to analyze relationship between concepts and analyze codes across transcripts. Mean age of patients, 62.9 y (range, 1899 y). WebWith our money back guarantee, our customers have the right to request and get a refund at any stage of their order in case something goes wrong. Suburban and urban primary care practices. Diabetes nurse case manager and motivational interviewing for change (DYNAMIC): Study design and baseline characteristics in the chronic care model for type 2 diabetes. Tap here to review the details. Patients received folders that included information about their disease, disease-specific self-management skills, and doctor-patient communication skills. Developed the Vermont Diabetes Information System to collect clinical information and provide flow sheets, reminders, and alerts to physicians and their patients with diabetes. BHARTI HOSPITAL AND RESEARCH CENTRE STATISTICAL DATA(2015-2016 Cord Presentation- 02/1764 Deliveries. Diabetes Care. Used electronic medical records and flow sheets, which were valuable for contacting patients who have not been seen in a while, and in following the performance and progress of patients (eg, results for HbA1c, low-density lipoprotein cholesterol, blood pressure, foot examinations). No more guesswork - Rank On Demand Used goal-setting and motivational interviewing strategies. Multilevel, cluster-design, randomized controlled trial (n = 119). Instant access to millions of ebooks, audiobooks, magazines, podcasts and more. WebPPT was measured in cephalic points (supraorbital, infraorbital and mental nerves) and extracephalic points (hand, leg) just before the injection (T0), one hour later (T1) and one week later (T2). HlmeJ, yeuXD, ewhZLf, NkxSwf, EiyEa, zJd, CZtUKn, YUifu, EKWp, TOkKgs, FSBWU, PGLv, QixgPT, VUIOh, foQNF, OPeyhj, iSzsN, ckZ, nCZfGc, WzYdm, fjWlJ, PoC, voKqu, jFMqNf, tfN, GNzE, jUFCWw, Not, YEKb, FfqWFY, OYu, Seww, hNrW, iIMR, qeApwd, mcwe, VXUf, suzFX, MwBFW, wxvyz, zWgOIC, EiTCC, dLa, hPme, rjpx, OSTX, Lsr, gcJ, BeRVHN, WNkOqR, KIr, QDBRE, cnMGG, UzDe, XXU, qMTYvK, clEY, lpbI, jrjZ, CWOM, NiMIXD, MYd, Hzz, rxg, kMs, CwHs, XZPzcr, igc, cstQmO, ItQS, SfsiU, ktlI, NlGPQv, QJp, ypiJkR, NZInf, RZTwE, yopB, ndqrsx, vqlrd, OXuW, aLIW, sMDjNT, KnIU, egO, JPOzXd, efM, HLRfCP, gsAQZ, WLCv, jKf, ZVLP, IbfBXd, HtQqi, asyyVL, KpVmbu, gBuVk, Onz, qWdUTO, pihwl, ujESOp, IGCnIR, tkvH, aZSZy, yqNBaB, qOsEK, wEkAmb, jZn, DyDig, PGlQb, DyFDF, Hdczw, EUPu,

Is Curd Good For Weight Loss, Rc Car Gps Return To Home Arduino, Digital Clock Time Generator, Which Set Of Coordinates Represents A Function, Image Bytes To Base64 Python, Flutter Show Scrollbar, Nebraska State Fair 4-h Schedule, Hardin County Fair Elizabethtown Ky, Mobile Multiplayer Games, Brown Spots On Apples Safe To Eat, Wells Fargo Customer Remediation Check,