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For specific types of troponin test A sensitive and specific blood test tubes virus facts order discount linezolid on-line, see their alphabetical listing. For example, the backcomplex of proteins found in skeletal and cardiac ward protrusion of the heel is called the tuber calmuscle. Normally, very low levels of troponin are canei or, alternatively, the tuberosity of the present in the bloodstream. Small tubers are a characteristic finding forms of damage to heart muscle release a certain in tuberculosis, and tubers in the brain are seen in subtype of troponin into the bloodstream, where it tuberous sclerosis. Diagnosis is made via Trypanosoma cruzi the microorganism that skin test, which if positive is followed by a chest Xcauses Chagas disease. T-suppressor cells close down the immune Quarantine is not needed for most patients with response after invading organisms are destroyed. See also suppressor cells are sensitive to high concentrations tuberculosis, active; tuberculosis, antibioticof circulating lymphokine hormones, and they resistant; tuberculosis, dormant; tuberculosis, release their own lymphokines after an immune miliary. T-suppressor count A test that counts the number tuberculosis, antibiotic-resistant A variant of of T-suppressor (T-8) cells in the bloodstream. Skin abnormalities are present in members and other contacts of diagnosed patients all cases of tuberous sclerosis. They include tiny may also need to take medications as a preventive benign tumors (angiofibromas) on the face and measure. The brain abnormalities of tuberous sclerosis are mainly tuberculosis, dormant the presence of benign cortical tumors (tubers) that cause seizures, Mycobacterium tuberculosis infection without a developmental delay, and mental retardation. Treatment involves a course of antibisis include arrhythmias and benign heart muscle otics and vitamins. It can be easily transmitted to Hunters and other people who spend much time others when someone who has it coughs. Rubber or latex gloves should be worn when skinning or handling animals, tuberculous diskitis A tuberculosis infection of especially rabbits. Untreated tuberculous One should try to avoid bites of deerflies and ticks diskitis can lead to inward or outward curvature of and avoid drinking, bathing, swimming, and workthe spine. Their names usually reflect the kind of tissue they arise in and tumor necrosis factor One of multiple proteins may also tell something about their shape or how capable of inducing necrosis (death) of tumor cells they grow. For example, a medulloblastoma is a that possess a wide range of proinflammatory tumor that arises from embryonic cells (a blastoma) actions. Benign tumors can sometimes simply be ignored, or they may be tumor registry Recorded information about the reduced in size (debulked) or removed entirely via status of patients with tumors. For cancerous tumors, options include was originally the place where information was colchemotherapy, radiation, and surgery. See also blaslected (in registers), the word registry has also toma; carcinoembryonic antigen test; desmoid come to mean the collection itself. A tumor registry tumor; ear tumor; epidermoid carcinoma; epitheis organized so that the data can be analyzed. For lial carcinoma; esophageal cancer; fibroid; example, analysis of data in a tumor registry mainsyringoma; tumor marker. The tunica albuginea helps to trap a tumor, because no tumor marker is entirely spethe blood in the corpora cavernosa, thereby sustaincific to a particular type of cancer, and because not ing erection of the penis. An example of a tunnel is when a particular tumor has been found with a the carpal tunnel. Tympanometry works by varying ized by polyps in the colon (large intestine) in addithe pressure within the ear canal and measuring the tion to tumors in the brain. The intelligence of air (pneumothorax) or the abdomen is distended those with Turner syndrome is usually within the with gas. Girls with Turner syndrome at the time of puberty do not experience the development type I error See alpha error. The ovaries typically contain no follicles and look like streaks of fibrous tissue. A typhoid fever An acute illness characterized by second sex chromosome may be present, but it is fever caused by infection with the bacterium not structurally and functionally normal. Diarrhea is uncommon, overwhelming majority of pregnancies with Turner and vomiting is not usually severe. Large epidemics are most often related to fecal contaminatwin One of two children produced in the same tion of water supplies or foods sold on the streets. Twins who people traveling to high-risk areas, such as the develop from two ova that are fertilized at the same Indian subcontinent and developing countries in time are called dizygotic or fraternal twins. They are Asia, Africa, and Central and South America where nonidentical and have different genomes. Typhoid vaccination is not tympanic membrane the eardrum, a thin mem100 percent effective and is not a substitute for brane that serves as a partition between the external careful selection of food and drink. Characteristic Symptoms include fever, a small ulcer (tache noire) symptoms include fever, headache, a raised (macuat the site of the tick bite, swollen glands near the lar) rash, swollen glands (lymphadenopathy), and a site of the tick bite (satellite lymphadenopathy), and dark crusted ulcer, called an eschar or tache noire, a red, raised (maculopapular) rash. The cause is a microorganism called Rickettsia typhus, urban, of Malaysia See typhus, prowazekii, which is found worldwide and is transmurine. Tyrosinemia type I is due to deficiency of fumarylacetoacetase, typhus, mite-borne See typhus, scrub. An acute form surfaces soon after birth, with acterized by fever, headache, and rash that are simithe odor of cabbage and death from liver failure in lar to , but milder than, those in epidemic typhus. A chronic form is characterized by chronic Murine typhus is caused by the microorganism liver disease, rickets due to hypophosphatemia (low Rickettsia typhi (mooseri) and transmitted to phosphate), and death in childhood. The aniassociation with liver cancer (hepatocellular carcimal reservoir includes rats, mice, and other rodents. Also known as endemic typhus, rat-flea areas on the palms and soles and in the cornea and typhus, and urban typhus of Malaya. Symptoms include fever, a small ulcer (eschar) at the site of the tick bite, swollen glands near the site of the tick bite (satellite lymphadenopathy), and a red, raised (maculopapular) rash. Peptic ulcer pain may not correlate with the presence or severity of ulceration. Complications of peptic ulcers include bleeding, perforation, and blockage of the stomach (gastric obstruction). Uu ulcer, stasis A skin ulcer that develops in an area in which the circulation is sluggish and the return of venous blood toward the heart is poor. Ulcers on the skin are usually due to irritation, as in the case of bedsores, ulna the larger of the two long bones within the and may become inflamed and/or infected as they forearm. Ulcers in the gastrointestinal tract were once is on the same side of the arm as the little finger. Ultraesophagus that is corroded by the acidic digestive sound waves can be bounced off tissues by using juices secreted by the stomach cells. Ultrasound imaging allows an inside view of soft tissues and body ulcer, gastric An ulcer in the lining of the stomcavities without the use of invasive techniques. Ulcer formation is related to Helicobacter pylori bacteria in the ultraviolet A See ultraviolet radiation. For example, the uterus is normally ultraviolet radiation Invisible rays that are part unicornuate. The light from tanning lamps is like that including matching potential donors and recipients. The umbilical arteries and vein unresectable Unable to be removed (resected) run within this cord. There are many causes for unsteadiness, oxygen deprivation, shock, injury, or use of central including problems in the cerebral or cerebellar nervous system depressants such as alcohol and portions of the brain, the spinal cord, vestibular sysdrugs. When the stomach, and small intestine) that are taken after a loss of consciousness is temporary and recovery is patient drinks a barium solution. See also barium spontaneous, it is referred to as syncope or, more solution; barium swallow.

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No scarring is evident infection kpc order 600 mg linezolid mastercard, but there are several resolving inflammatory lesions (blue arrow). These lesions may remain erythematous or violaceous for months and are often confused with scars. There are inflammatory papules and pustules (red arrow), open comedones (yellow arrow), and resolving inflammatory lesions (blue arrow). Key among these are disordered keratinization (leading to obstruction within pilosebaceous follicles), increased sebum production (which contributes to obstruction), and inflammation (due, in large part, to activation of the immune system by the bacterium, Propionibacterium acnes). As obstruction increases, follicles may rupture, contributing to the inflammatory process. On the face, scars appear as small pits, while on the trunk, they are hypopigmented macules. Treatment plans, especially for those who have moderate or severe disease, should be designed to impact as many aspects of the disease pathophysiology as possible. In such cases, it is important to note that follicular obstruction is present, even if blackheads (open comedones) and whiteheads (closed comedones) are not observed. In addition, because the adolescent has moderate acne limited to the face, has no scarring, and is using no medication, an attempt to manage the inflammatory component of her disease with topical agents is reasonable. Although topical retinoids have some anti-inflammatory activity, the number of papules and pustules exhibited by the adolescent in the vignette indicates the need for specific treatment of this component of her disease. Suggested treatment plans for mild, moderate, and severe acne are presented in Item C63B, Item C63C, and Item Item C63D. Obstruction within follicles is present and should be addressed, even if blackheads and whiteheads are not observed. As she was not spontaneously breathing in the emergency department, the girl was endotracheally intubated. On painful stimulus, the girl exhibited extensor posturing, but did not open her eyes. No therapeutic modalities have been proven to prevent secondary injury after cardiac arrest from drowning in children, therefore therapy should consist of supportive care and maintenance of blood pressure, oxygenation, and ventilation. Of the response choices listed, maintenance of arterial hemoglobin oxygen saturation greater than 93% is most appropriate. Approximately one in five people who die from drowning are age 14 years or younger. Children ages 1 to 4 years have the highest drowning rates, most occurring in home swimming pools. In that age group, drowning is the second most common cause of death (the first being congenital anomalies). Risk factors for drowning include poor swimming ability, inadequate barriers around the pool, lack of supervision, and alcohol use (for older children and adults). Pediatric health supervision visits should include anticipatory guidance that emphasize supervision, swimming skills, avoidance of alcohol, and installation of appropriate barriers and alarms around home pools. When water enters the airway, the diving reflex is stimulated, causing apnea, bradycardia, and laryngospasm. Although laryngospasm can prevent further aspiration of water, it impairs oxygenation and ventilation. Water or aspirated vomitus in the airspaces can cause abnormal surfactant production and hypoxia from ventilation-perfusion mismatch, leading to intrapulmonary shunting, poor lung compliance, and acute respiratory distress syndrome. Ventilator management should be targeted toward recruitment of lung volume and maintenance of oxygenation and ventilation. Hypoxia, hypercarbia, acidosis, and the resultant decreased myocardial contractility can lead to asphyxial cardiopulmonary arrest. Asphyxial cardiac arrest can cause death or long-term encephalopathy, resulting from both hypoxic-ischemic and reperfusion injury. Supportive critical care ensuring adequate oxygenation, ventilation, hemodynamics, and nutrition is recommended. Extensive clinical trials investigating various treatments for cardiac arrest after drowning were undertaken in the 1970s and 1980s including therapeutic hypothermia, hyperventilation, osmotherapy, and goal-directed therapy to limit intracranial pressure. Although hyperventilation can lower intracranial pressure, it is not recommended after cardiac arrest because it can exacerbate cerebral ischemia. There are ongoing multicenter clinical trials investigating therapeutic modalities after pediatric cardiac arrest. On physical examination, she is irritable, has a facial droop, and left-sided weakness and tremor. Malnutrition, specifically protein calorie malnutrition as described for the girl in the vignette, can alter Th1 immune responses, leading to lymphocyte anergy and thus increased risk for progression from latent tuberculosis infection to tuberculosis disease. Overall, both lack of adequate macroand micronutrients can be associated with immune dysfunction and infections. Protein-calorie malnutrition has been associated with varied immune dysfunction, including atrophy of lymphoid tissue, decreased cell-mediated immunity, decreased immunoglobulin and complement levels, and diminished phagocytosis. Vitamin D and zinc deficiencies have also been linked to impaired immune responses. While malnutrition can be associated with altered innate immunity, such as decreased phagocytic cell function, adaptive immunity is felt to be more critical in responding to intracellular pathogens, such as mycobacteria. Natural killer cells are a component of the innate immune system and are critical in immunity against viral infections. Deficiency of natural killer cells is associated with increased susceptibility to infection, especially Herpesviridae. Decreased regulatory T-cell function can be associated with increased autoimmune and atopic disease. Vital signs show a respiratory rate of 26 breaths/min, heart rate of 110 beats/min, and blood pressure of 138/90 mm Hg. On physical examination, he has facial puffiness, but the remainder of the examination is unremarkable. Facial puffiness, respiratory distress, and high blood pressure, as present in the patient in the vignette, are indicative of volume overload. Such patients are managed with volume restriction (two-thirds maintenance) and intravenous furosemide for achieving diuresis and net negative fluid balance. Loop diuretics (furosemide, bumetanide, torsemide) inhibit sodium absorption via the Na-K-2Cl channels in the medullary and cortical aspects of the thick ascending limb, leading to excretion of up to 20% to 25% of tubular sodium. All diuretics inhibit sodium reabsorption at different sites in the nephron, thereby increasing sodium and water losses in urine. Intravenous furosemide (onset of action: oral, sub-lingual: 30-60 minutes; intramuscular: 30 minutes; intravenous: approximately 5 minutes) has a rapid onset of action, and in patients with pulmonary edema symptomatic improvement, in 15 to 20 minutes prior to the onset of the diuretic effect has been reported. The thiazide diuretics (chlorothiazide) have a decreased natriuretic and diuretic effect compared to loop diuretics and inhibit the reabsorption of 3% to 5% of filtered sodium in the distal tubule. Thiazide diuretics inhibit sodium entry via the Na-Cl cotransporter in the distal nephron. Thiazides are not the preferred diuretics for the patient in the vignette, in view of the decreased diuresis in comparison to loop diuretics and slower onset of action (oral, within 2 hours; intravenous, 15 minutes). However, thiazide diuretics are preferred over loop diuretics for chronic antihypertensive therapy and have been commonly used for management of primary hypertension, especially in adults. However, the volume depletion is blunted because of the activation of the renin-angiotensin system in response to hypovolemia. The factors responsible for the chronic vasodilation with prolonged thiazide treatment remain unclear. The dihydropyridine calcium channel blockers act on the vascular smooth muscles and are potent vasodilators with minimal (or no) negative effect on cardiac contractility. Intravenous hydralazine is most frequently used for hypertensive emergencies in the emergency department, intensive care unit, or inpatient hospital settings. In patients with severe acute renal failure and oliguria or anuria resistant to aggressive diuretic therapy, intravenous hydralazine or oral nifedipine may be used for hypertensive emergencies. The child was diagnosed with extrahepatic biliary atresia at 7 weeks of age and underwent a hepatoportoenterostomy (Kasai procedure).

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A markedly elevated platelet count with impaired There is risk of progression to other hematologic disorders platelet functionis typically associated antibiotic eye drops stye discount 600 mg linezolid overnight delivery. Essential (bone marrow failure, acute myelogenous leukemia, chronic thrombocythemia has highest platelet count which may myelomonocytic leukemia). Treatment is experimental and may high platelet count, the term "thrombocytosis" is preferred. Secondary thrombocytosis is more common condition and the development of secondary hematologic than primary thrombocythemia [1]. Reactive thrombocytosis or secondary thrombocythemia is Eosinopenia an overproduction of platelet in response to another disorder, A low number of eosinophils in the blood (eosinopenia) can increased platelet levels may last for days to weeks, although occur with Cushing syndrome, bloodstream infections (sepsis), platelet function is normal. However, a low number of acute and chronic blood loss acute infection, chronic eosinophils do not usually cause problems because other parts inflammatory disorders (inflammatory bowel disease, of the immune system compensate adequately. A low number tuberculosis, sarcoidosis rheumatoid arthritis) splenectomy, of eosinophils are usually detected by chance when a complete iron deficiency, rebound thrombocytosis in recovering blood count is done for other reasons. Treatment of the cause alcoholics or patients on chemotherapy and certain cancers. Eosinophils usually Thrombocytopenia account for less than 7% of the circulating white blood cells this is an abnormally low platelet count of less than (100 to 500 eosinophils per microliter of blood). Sometimes, eosinophils cause the emergency room with acute, severe thrombocytopenia, inflammation in certain organs and result in symptoms. Basophil has some role in immune thrombocytopenia is important since early thrombocytopenia surveillance (such as detecting and destroying very early is usually due to postoperative hemodilution, whereas 40 Esan Ayodele Jacob: Complete Blood Cell Count and Peripheral Blood Film, Its Significant in Laboratory Medicine: A Review Study later-onset thrombocytopenia suggests heparin-induced (3) Poikilocytosis: Variation in shape thrombocytopenia, septicemia, or other postoperative (4) Presence of inclusion bodies complications [2]. Variation in erythrocyte size is now platelets, and a combination of these mechanisms. Microcytosis is seen in: Iron thrombocytopenia due to immune-mediated platelet deficiency anemia, thalassemia, lead poisoning, destruction (commonly, heparin, sideroblastic anemia and anemia of chronic disorders as trimethoprim/sulfamethoxazole), Drug-induced shown in figure A6 of the appendix. Acquired disorders in color with a pale center after staining the blood of platelet function are commonly due to diseases (renal smear with Rowmanosky dye because the failure) as well as to aspirin and other drugs [33]. Qualitative Abnormalities of Blood Cells red cells is reflected by its haemoglobin content. Qualitative abnormalities may involve all the blood cells; Increased haemoglobinization is termed red cell morphology evaluation include examination for hyperchromia. Decreased haemoglobination is deviations in size, shape, distribution, concentration of hypochromia [6, 9]. This cells and their overall appearance which includes nuclear variation is seen in: Iron deficiency anemia, anemia of abnormalities, cytoplasmic abnormalities and the presence of chronic diseases, thalassemia, some hemoglobinopathies, abnormal inclusions that denote a disease process. Platelet sideroblastic anemia and any of the conditions leading to count should be verified and in addition the smear should be microcytosis as shown in figure A2 and A3 of the reviewed for platelet shape and size abnormalities and for appendix. Often slightly larger than normal red Mature red blood cells are biconcave discs that lack nucleus cells and round in shape round macrocytosis. This and most cell organelles such as lysomes, endoplasmic variation is seen in:Any situation with reticulocytosis reticulum and mitochondria [13]. However, variable abnormal for example bleeding, haemolysis or response to erythrocyte morphology is found in various pathological haematinic factor replacement. Stomatocytes are found in: excess alcoholism, alcoholic Dimorphic Blood Picture is the two distinct populations liver disease, hereditary stomatocytosis, Hereditary of red cells. The populations may differ in size, shape or spherocytosis as shown in figure A20 of the appendix. Burr cells are found in in large blood vessels but their shape changes to hemolytic anemia, uremia, megaloblastic anemia as parachute like confirmation in capillaries. Thalassemia major, hereditary ovalocytosis, sickle cell these are found in cold agglutinations, warm anemia as shown in figure A13 of the appendix. These are found in hyperglobulinemia, thalassemia, myelofibrosis as shown in figure A13 of the hyperfibrinogenaemia [1, 13] as shown in figure A9 of appendix. Target cells: Red cells have an area of increased staining (4) Presence of inclusion bodies: Red blood cells have which appears in the area of central pallor. Reticulocytes appear as polychromatic cells on Projections vary in width but usually contain a rounded Rowmanosky stained slides. Spherical cells with 2 20 spicules of unequal newly released from the marrow sinusoids and takes 42 Esan Ayodele Jacob: Complete Blood Cell Count and Peripheral Blood Film, Its Significant in Laboratory Medicine: A Review Study about a day or two to mature in the peripheral circulation cases where the underlying cause is due to a combination of in those with intact spleen [35] as shown in figure A29 of factors such as iron deficiency (a cause of microcytosis) and the appendix. Their presence on blood Morphology of White Blood Cells, Interpretations and film suggests a severe stress on the marrow forcing their Clinical Significant premature release. As a rule, a stressors as seen in hypoxia, severe anaemia (haemolytic leucocyte/hpf approximates about 200 and 2000 cells in or haemorrhagic) and severe sepsis, marrow infiltrations peripheral blood at x10 objective and x100 objective (due to leukaemia, lymphoma, myeloma or secondary respectively. In the bone marrow, they differentiate into two groups: iron deposits which as dense blue, irregular granules in granulocytic and lymphoid cells [10]. The half-life of mature neutrophils in Basophilic stippling: these are considerable amount of circulation is about 7 hours. These are the remnants of Sessile Nodule: Inactive X chromosome found as nodule nuclear membrane. Found in: Neutrophils of Parasites of red cells: Protozoan parasites, delicate rings females as shown in figure A42 of the appendix with 1 or 2 chromatin dots. Often more than one ring in a Hypersegmentation or right shift of neutrophil nuclei: red cell like one of the four species of the malaria Average lobe count increased or increased % of parasite may be seen in case of malarial infection [1, 4, 8, neutrophils with 5 6 lobes or greater than 3% 13] as shown in figure A30 of the appendix. Found in: However, morphology of Red blood cell can be used to Megaloblastic anaemia, Iron deficiency, Chronic classify anaemia based on the size of red blood cells. This scheme quickly figure A44 of the appendix exposes some of the most common causes of anemia; Detached nuclear fragments: Detached nuclear material microcytic anemia is often the result of iron deficiency. American Journal of Laboratory Medicine 2016; 1(3): 34-57 43 Found in: Inherited, Refractory anaemia, Blast crisis of more condensed chromatin. Granulation Chronic granulocytic leakaemia, Therapy with more basophilic and larger than normal. Toxic granulations are seen in the Neutrophil aggregation: Small clumps of neutrophils. It has life time cytoplasm of neutrophil Found in:Infection, Auto of a few hours to a few days. In anaemia,Chronic infection as shown in figure A49 of the the peripheral blood, approximately 15 to 25% of appendix lymphocytes are B cells and 40 to 75% are T cells. It has life Necrobiotic / Apoptotic neutrophil: Dense homogenous time of Years for memory cells, weeks for all else [30, 31]. Basophilia may be confined to the Shift to the Left: Presence of precursor of granulocytes in cytoplasmic margins. Severe neutrophilia with shown in figure A55 of the appendix left shift is termed leukaemoid reaction [4, 14, 32] as Plasmacytoid Lymphocyte: Lymphocyte with basophilic shown in figure A32 of the appendix cytoplasm and eccentric nucleus. Found in: Reactive Pseudo Pelger Huet Anomaly: Bilobed neutrophils with phenomenon as shown in figure A57 of the appendix 44 Esan Ayodele Jacob: Complete Blood Cell Count and Peripheral Blood Film, Its Significant in Laboratory Medicine: A Review Study Mott cell: Plasmacytoid lymphocyte with globular Wiskott Aldrich syndrome as shown in figure A68 of the inclusions composed of immunoglobulin. Found in: appendix Reactive changes in peripheral blood as shown in figure Grey Platelet Syndrome: Platelets appear degranulated. A58 of the appendix Found in: Grey platelet syndrome, Discharge of platelet Large Granular Lymphocyte: Small eosinophilic granules in vivo (cardiopulmonary bypass, hairy cell granules in the cytoplasm of large lymphocytes Found in: leukemia), Discharge of platelet granules in vitro (poor Natural killer cells, Lymphokine activated T cells [2, 10, venesection technique), [8, 13, 14, 32] as shown in figure 30] as shown in figure A59 of the appendix. They can ingest particles such as cellular debris, bacteria, or other insoluble Blood Cell and Differential White Cell particles. Count Test Monocyte Vacuolization: Vacuoles in the cytoplasm of monocytes Found in: Infections[10, 30] as shown in Leukocytes can be evaluated through several techniques figure A60 of the appendix both manually and automation of varying complexity and Morphology of Platelets, Interpretations and Clinical sophistication. Both quantitative and qualitative properties can Significant be assessed in the laboratory.

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M icroalbum inuria is potentially reversible and m ay be associated with norm al renal function antimicrobial cutting boards order cheapest linezolid. Studies in white populations estim ate progression from m icroalbum inuria to overt proteinuria as 30 per cent over 10 years. Despite the differences in m ethodology, sizes of cohorts and the definitions of m icroalbum inuria used, the overall prevalence of m icroalbum inuria in South Asians is estim ated to be between 25 per cent and 40 per cent. Studies from Southern India also report sim ilarly higher levels of m icroalbum inuria. The overall prevalence of m icroalbum inuria in a study from South India, was around 36 per cent; further, m icroalbum inuria was present in nearly a quarter of those with 9 newly diagnosed diabetes. In the Chennai Urban Rural Epidem iology Study, the 10 prevalence of m icroalbum inuria was 27 per cent. Increasing age, duration of diabetes, sm oking and hypertension are recognised 9,13 risk factors for m icroalbum inuria. The increased susceptibility of South Asians, however, appears to be independent of these risk factors. In a study com paring the prevalence of m icroalbum inuria in Europeans and different subgroups of South Asians, significantly higher levels of urinary album in excretion were observed in South Asians independent of their age and the presence of diabetes or 13 hypertension. M oreover, the relationship between blood pressure and m icroalbum inuria m ay be different in South Asians. Apart from being a m arker of nephropathy, m icroalbum inuria is an independent risk factor for 14 cardiovascular disease, and the higher prevalence of m icroalbum inuria in South Asians is consistent with the excess cardiovascular risk observed in this population. Progression rates m ay vary from individual to individual, however, and between ethnic groups. Not all studies support this, however, and although it is generally believed that progression rates are faster in South Asians, the paucity of long-term studies m akes this difficult to verify. The risk of cardiovascular disease and death from cardiovascular causes increases 3 with the degree of proteinuria. Cardiovascular risk is significantly higher in South Asians, and the presence of renal disease m ay further exacerbate this. There are, however, no studies in South Asians to exam ine the effect of renal disease on m ortality. Thus, there appears to be a reduction in the rate of acceptance of South Asians onto renal replacem ent program m es, and indeed there is a longer delay in enrolm ent to such program m es for South Asians com pared to white populations. Given the high prevalence of diabetes in South Asians, it is reasonable to assum e that the num ber of South Asians needing renal replacem ent therapy would at least be proportionate to the prevalence of diabetes, if not higher. Risk factors and m anagem ent Diabetic nephropathy can be regarded as a potentially reversible com plication, and the ability to detect the disease in early stages has m ade it possible to intervene 4 and alter the natural course of the disease. Age, duration of diabetes, glycaem ic control, blood pressure and sm oking are considered m ajor risk factors for nephropathy. Effective m anagem ent of nephropathy requires an effective screening 20 strategy com bined with aggressive m anagem ent of risk factors. Currently, there are no ethnic-specific screening strategies, and ethnicity as a risk factor is not universally recognised. Given the relatively high risk of nephropathy and cardiovascular disease, annual screening m ay be appropriate in South Asians. There is substantial evidence to suggest that both tight glycaem ic and blood pressure control can reverse or slow the progression of renal disease. Epidem iological studies have shown that tight glycaem ic control decreases the risk of progression from 21 norm oalbum inuria to m icroalbum inuria. The role of glycaem ic control after the onset of overt proteinuria, however, is less certain. Sim ilarly, tight blood pressure control has been shown to reduce significantly the risk of progression to 22 m icroalbum inuria. Presently, there are no random ised controlled trials involving South Asians to exam ine the benefits of glycaem ic control and blood pressure. W hat m ust be rem em bered, though, is that the thresholds for treatm ents m ay vary between ethnic groups, and that m ore studies involving South Asians are required to establish ethnic-specific targets. A significant proportion of patients with proteinuria m ay have non-diabetic renal disease. As the prognosis and m anagem ent of these conditions m ay be considerably different, it is essential to establish the correct diagnosis. The increased awareness of the risk of nephropathy and cardiovascular disease in the South Asian population has generated a lot of interest am ong healthcare professionals in recent years. The role of ethnicity in disease causation, however, rem ains unclear and is further ham pered by the lack of adequate clinical trials in this population. Nephropathy is a m ajor com plication of diabetes and is also potentially reversible. Despite this, our knowledge of this condition in South Asians is lim ited to a few cross-sectional studies. Investigations into the causes that lead to this excess risk, and strategies to effectively m anage these patients, are clearly needed to reduce the m orbidity and m ortality associated with this condition. Com parison of prevalence and risk factors for m icroalbum inuria in South Asians and Europeans with Type 2 diabetes m ellitus. South-Asian Type 2 diabetic patients have higher incidence and faster progression of renal disease com pared with Dutch-European diabetic patients. Prevalence of m icroalbum inuria in Type 2 diabetes m ellitus at a diabetes centre in southern India. The relationship between proteinuria and coronary risk: a system atic review and m eta-analysis. The effect of ethnicity on the prevalence of diabetes and associated chronic kidney disease. Rate of decline in renal function in Indo-Asians and W hites with diabetic nephropathy. Intensive blood glucose control and vascular outcom es in patients with type 2 diabetes. Effects of Losartan on renal and cardiovascular outcom es in patients with Type 2 diabetes and nephropathy. Therapeutic intervention can potentially reduce risk through 2,3 im provem ents in glycaem ic control and blood pressure, supporting behaviour change such as healthy eating and increasing physical activity, and through use of 4 agents that im prove lipid profiles. Sum m ary of current evidence There rem ains conflicting evidence with regard to the epidem iology of diabetic 6,10 1 retinopathy in South Asians. M ost of these risk factors are potentially am enable to im provem ent but im proving 11,12 glycaem ic control rem ains a substantial challenge in South Asian com m unities. A consistent finding in studies on the m icrovascular com plications of diabetes is that the duration of diabetes and age at onset together with glycaem ic control are strong 98 Chapter 15: Diabetic retinopathy 2 and well-established risk factors in the developm ent of retinopathy. The differential risk of retinopathy between South Asians and white 1 Europeans is largely observed in those with diabetes duration of less than 10 years. This highlights the need for screening and earlier diagnosis of diabetes in South Asian populations. It suggests that the pathogenesis of diabetic retinopathy in these 1,7,8 groups m ay be m ore aggressive than in white Europeans. The prevalence of diabetic retinopathy reported from large-scale studies of South Asians in India is lower than in white European populations (17 per cent versus 37 per cent). These studies confirm that earlier age, duration of diabetes, m ale gender 8,9 and elevated HbA1c are risk factors within the indigenous population. An increase in blood pressure from the adoption of a m ore westernised lifestyle is 1,9 proposed as the causal link to explain these changes. This hypothesis clearly needs m ore research, with studies com paring populations and their m igration, and its effect not only on the m igrant group but subsequent generations.

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Women with type 2 diabetes obesity for sleepfidisordered breathing prior should be screened for depression antibiotics tired purchase linezolid 600 mg online. Depression is associated with adverse pregHowever, it remains to be determined if nancy outcomes (preterm delivery, preectreatment for sleepfidisordered breathing will lampsia, and growth restriction) and should improve pregnancy outcomes. Type 2 diabetes is associated with an increased risk of cancers of the liver, panObesity creas, colon, breast, bladder, and endomeUp to 80% of patients with type 2 diabetes are trium (57). Obesity is associated with signifiwomen with type 2 diabetes to undergo cant pregnancy complications, including agefiappropriate screening either prior to stillbirth, cesarean, preeclampsia, macrosoconception or postpartum (58). If seen prior to conception, women Fatty Liver Disease should be counseled to attempt to achieve a Type 2 diabetes may be associated with unexnormal body mass index prior to pregnancy. If seen during pregnancy, women should be this is likely part of the metabolic syndrome advised to follow a healthy diet and 30 min of frequently associated with type 2 diabetes, moderate exercise daily. Vascular disordered breathing or obstructive sleep complications of diabetes (nephropathy, apnea, may be more prevalent in those with retinopathy, and heart disease) are more type 2 diabetes (52,53). This is likely related closely associated with the risk of adverse to the relationship of obesity with type 2 outcomes than is the type of diabetes (29). In diabetes and obstructive sleep apnea rather a cohort of 468 women with diabetes, the risk Problems Encountered More Frequently in Women with Type 2 Diabetes 183 of adverse outcomes was similar between metformin, the firstfiline agent for treating type 1 and type 2 diabetic subjects without diabetes. Glycemic control is particularly vasculopathy, whereas the risk of adverse important in those who had a cesarean delivoutcomes (except for fetal overgrowth and ery as hyperglycemia may hinder wound shoulder dystocia) sharply increased for both healing and places patients at risk for wound types of diabetes complicated by vasculopainfection. However, the risk of fetal bidities (as listed in this chapter), with preovergrowth and shoulder dystocia was scription of appropriate medications and decreased in those with vasculopathy. In referral to an appropriate managing physispite of the decreased risk of fetal overcian as necessary. The postpartum period is growth, the risk of cesarean remained high in an excellent time point for contraceptive those with vasculopathy, suggesting that counseling as many women will be highly cephalopelvic disproportion is not the only motivated to use contraception at this time. Unless other contraindications exist, women with type 2 diabetes should be encouraged to breastfeed their infants. In Postpartum Management women with a history of gestational diabetes, those who exclusively breastfeed their infants Postpartum, most women may revert to their have improved glycemic profiles compared prefipregnancy medications. Similar was on oral medications before, these can improvements in the glycemic profile can be typically be restarted, particularly if she had expected in those with type 2 diabetes as evidence of good glycemic control prior to well. Women who were diagnosed insulin are not contraindications to breastearly in pregnancy may be given a trial of feeding (see Chapters 15 and 26). Vasculopathy (nephropathy, retinopathy, heart No vasculopathy disease) Type 1 Type 2 Type 1 Type 2 n= 107 n= 297 n= 40 n= 24 Neonatal/fetal complications Composite neonatal outcome 11% 13% 21% 25% Stillbirth 2. Research is ongoing regarding the A True use of metformin and glyburide for type 2 diaB False betes during pregnancy, although many now use them as the firstfiline agents for gestational this statement is false. The National Pregnancy in estimates of diabetes prevalence for 2013 Diabetes Audit Report, 2014: England, Wales, and projections for 2035. Pregnancy outcome among children and adolescents from 2001 in patients with insulinfidependent diabetes to 2009. Glycemic control prevents congenital Findings of a National Enquiry: England, anomalies. Problems Encountered More Frequently in Women with Type 2 Diabetes 185 Effectiveness of a regional prepregnancy et al. Health, Lippincott Williams & Wilkins: sociodemographic data, and pregnancy Philadelphia, 2011. Risk of outcomes: a systematic review and metafi congenital anomalies in pregnant users of analysis. Nutritional epidemiology of type 46 Cnattingius S, Bergstrom R, Lipworth L, 2 diabetes and depressive symptoms. Maternal obesity Maternal prenatal depressive symptoms and pregnancy outcome: a study of 287,213 and spontaneous preterm births among pregnancies in London. Some international guidelines recommend metformin as firstfiline treatment in women with gestational diabetes who do not achieve optimal glycemic control with lifestyle modifications, while others suggest metformin can be used as secondfiline treatment after insulin. Among women with type 2 diabetes, glibenclamide should be preferentially switched to insulin or metformin during pregnancy. Her HbA1c is 9% while on metformin 1 g twice daily and glibenclamide 10 mg twice daily. She has implemented lifestyle modifications and is on an appropriate diabetic diet, but her blood sugars remain above target. The meglitinides include Diabetes in pregnancy is associated with nateglinide and repaglinide. Meglitinides adverse pregnancy outcomes if glycemic have a more rapid antifihyperglycemic control is inadequate during pregnancy (1). However, with risthe human cotyledon perfusion model has ing prevalence of diabetes among women of been used to explore the mechanism of action reproductive age (2), an increasing number of sulfonylureas given the concern for neonatal of women are conceiving while taking oral hypoglycemia should it cross the placenta. In cases where involves the placenta being obtained from a women may be nonfiadherent, decline to take healthy mother at delivery and testing the relemultiple daily injections of insulin, or lack vant drug with perfusion and transfer studies. The only study examining Sulfonylureas and placental transfer of meglitinides noted the Meglitinides maternalfitofifetal transfer of repaglinide at 1. Firstfigeneration sulfonylureas Women with Type 2 Diabetes are rarely used due to a high incidence Analyzing the potential teratogenicity of any of adverse reactions. Secondfigeneration drug in pregnancy complicated by diabetes sulfonylureas possess better safety profiles is confounded by the fact that maternal Advances in Oral AntifiDiabetes Drugs in Pregnancy 191 hyperglycemia during first trimester is itself neonatal death among women with firstfi a potential teratogen. Eight patients (4%) in anomalies with meglitinide use, but two the glibenclamide group needed insulin. In a recent metafianalysis of switched to insulin at the beginning of pregrandomized controlled trials examining perinancy or who were treated with insulin alone. Maternal gestational age, or comorbidities between hypoglycemia was reported in two studies; groups. The reason for this increased rate of one study reported a lower incidence of perinatal mortality is unclear. However, a maternal hypoglycemia in women taking metafianalysis (10 studies on 471 exposed glibenclamide compared to insulin (20), women to sulfonylureas and biguanides in while another found a similar incidence (23). The average treatment failure Metformin freely crosses the placenta as among these studies was 26. Pregnancy: Summary Glibenclamide crosses the placenta but does Clinical Experience with Metformin not appear to be teratogenic. There are little data this has not been confirmed in a metafianalysis on the use of sulfonylureas in pregnant women of 17 randomized controlled trials of metwith type 2 diabetes. Based on a single retroformin use in the preconception period, where spective study, there is some concern regardmetformin was discontinued in the first triing increased perinatal mortality with mester (33). There is conflicting evidence continued use of glibenclamide throughout regarding the benefits of metformin to improve pregnancy, but this has not been reproduced pregnancy and live birth rates compared with in other studies. The rate of the primary composite outcome of neonatal morbidity, which Other Morbidity and Mortality included neonatal hypoglycemia, respiratory Women with Type 2 Diabetes distress, need for phototherapy, birth trauma, A retrospective study in South Africa noted a 5 min Apgar score less than 7, and prematuthat while perinatal mortality was higher in rity, was not significantly different in women women taking glibenclamide alone or in comassigned to metformin and those assigned to bination with metformin, there was no insulin. A recent randomized, in the metformin group, but preterm birth openfilabel study of 206 women not previously was more common in the metformin group on insulin with type 2 diabetes in pregnancy (12. There was no compared metformin versus insulin, where significant difference in glycemic control insulin could be added to metformin if between the groups, although 46. Total fat mass and percentage babies were more common in the metformin body fat assessed by bioimpedance and group (39). These drugs are not absorbed into Observational and cohort studies among the bloodstream in any significant amount.

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E Recently antibiotic cefdinir purchase 600mg linezolid otc, risk scores and other cardiothostatic blood pressure measurements vascular biomarkers have been develshould be checked on initial visit and as Randomized clinical trials have demonoped for risk stratification of secondary indicated. The benefits and pressure assessment may be useful to risks of intensifying antihypertensive monitor antihypertensive treatment. Notably, there mon among patients with either type 1 home blood pressure monitoring may is an absence of high-quality data availor type 2 diabetes. The Action in Diabetes automated office blood pressure measurefor patients who may derive the most and Vascular Disease: Preterax and ment,whichyieldsvaluesthataregenerally S106 Cardiovascular Disease and Risk Management Diabetes Care Volume 42, Supplement 1, January 2019 lower than typical office blood pressure provider judgment (35). A 2014 CoSome investigators have argued that the baseline blood pressure levels (11,37). Among trials with higher risk of adverse effects of intensive ditions during pregnancy. Taken together, these may prefer higher blood pressure targets known to be effective and safe in pregmeta-analyses consistently show that to enhance quality of life. In such patients, a blood control in pregnancy but may be used Individualization of Treatment Targets pressure target of,140/90 mmHg is duringlate-stagepregnancy ifneededfor Patients and clinicians should engage in recommended, ifit can besafely attained. Single-pill antihypertensive comto lifestyle therapy, have for additional information. IniLifestyle Intervention demonstrated to reduce cartial treatment for hypertension should Recommendations diovascular events in patients include any of the drug classes demon10. A duce mortality as blood pressure-lowering ducing excess body weight through calo10. Titration of and/or macologic therapy when hypertension is receptor blocker, or diuretic, addition of further blood pressure medidiagnosed (Fig. A lifestyle therserum creatinine/estimated cations should be made in a timely fashion apy plan should be developed in collaboglomerular filtration rate and to overcome clinical inertia in achieving ration with the patient and discussed as serum potassium levels should blood pressure targets. B Pharmacologic Interventions gests that there is an association between the absence of nocturnal blood Recommendations Initial Number of Antihypertensive Medications. A meta-analysis of randomized based blood pressure $140/90 tes depends on the severity of hypertension clinical trials found a small benefitof mmHg should, in addition to (Fig. Those with blood pressure beevening versus morning dosing of antihylifestyle therapy, have prompt tween 140/90 mmHg and 159/99 mmHg pertensivemedicationswithregardtoblood initiation and timely titration may begin with a single drug. For patients pressure control but had no data on clinical of pharmacologic therapy to with blood pressure $160/100 mmHg, effects (61). A initial pharmacologic treatment with single subsequent randomized controlled 10. Detection sium should be monitored during treatHyperkalemiaandAcuteKidneyInjury. C also be obtained immediately before initiata diuretic and two other antihypertensive ing statin therapy. In general, barriers to medication age, diabetes type, pharmacologic responding in spite of medication adheradherence (such as cost and side eftreatment, lipid levels, and medical ence, clinical judgment is recommended fects) should be identified and addressed conditions. Mineralocorticoid receptor antag(such as in oats, legumes, and citrus) extremely low, less than daily statin onists also reduce albuminuria and intake (74). However, adding a mineraloparticularly in patients with very high Statin Treatment corticoidreceptorantagonisttoaregimen triglycerides and poor glycemic control. Therelative tors, it is reasonable to conincluding data from over 18,000 patients benefit of lipid-lowering therapy has been sider high-intensity statin withdiabetesfrom14randomizedtrialsof uniform across most subgroups tested therapy. As such, Initiating Statin Therapy Based on Risk diabetes but is sometimes the only dose recent guidelines recommend that in paPatients with type 2 diabetes have an of statin that a patient can tolerate. Before initiating combination lipid-lowering therapy, consider the potential for Age < 40 Years and/or Type 1 Diabetes. Patients risks and consider the use of moderatewere randomized to receive subcutaneintensity statin therapy. Secondary Prevention (Patients With trolled trial in 18,144 patients comparing During the median follow-up of 2. Overall,theadditionof tively, representing a 15% relative risk intensity statin therapy is recommended ezetimibe led to a 6. Together, they group on average and 54 mg/dL in the prising 11,031 patients (40% of the found reductions in nonfatal cardiovascular combination group (90). S112 Cardiovascular Disease and Risk Management Diabetes Care Volume 42, Supplement 1, January 2019 Treatment of Other Lipoprotein increase in ischemic stroke in those on vascular disease outcomes and Fractions or Targets combination therapy (104). A total of 25,673 patients glyceridemia and consider risk of stroke with additional with prior vascular disease were randommedical therapy to reduce sideeffects,andisgenerallynot ized to receive 2 g of extended-release theriskofpancreatitis. In patients this specific population of patients is with moderate hypertriglyceridemia, ongoing (103). Diabetes With Statin Use lifestyle interventions, treatment of secSeveral studies have reported amodestly ondary factors, and avoidance of mediStatin and Niacin increased risk of incident diabetes with cations that might raise triglycerides are the Atherothrombosis Intervention in statin use (106,107), which may be limrecommended. In addition, the most recent sysof aspirin specifically in patients with events (characterized as mild) occurred tematic review of the U. The rate of major hemdementia is not currently supported by lectively enrolled over 95,000 particorrhage per 1,000 person-years was evidence and should not deter their use ipants, including almost 4,000 with 8. The excess mg/day) as a secondary preCardiovascular Events iN Diabetes) trial risk may be as high as 5 per 1,000 per vention strategy in those with randomized 15,480 patients with diabeyear in real-world settings. The primary plications do not have equal effects on and documented aspirin alsafetyoutcomewasmajorbleeding(i. In contrast, major bleeding mg/day) aspirin for primary prevention benefits beyond this period. A for using aspirin as primary prevention the required dose of aspirin for cardio10. Many alternate pathways for ence of any of the following: additional major risk factor (family hisplatelet activation exist that are indeatypical cardiac symptoms. Nonmeasured by a variety of ex vivo and sient ischemic attack, stroke, invasive imaging techniques such as in vitro methods (platelet aggregometry, claudication, or peripheral arcoronary computed tomography angiogmeasurement of thromboxane B2) (134), terial disease; or electrocarraphy may potentially help further tailor but other studies suggest no impairment diogram abnormalities. For patients over the that more frequent dosing regimens of Treatment age of 70 years (with or without diabeaspirin may reduce platelet reactivity in 10. B may be considered in the context of high analysis raised the hypothesis that low10. B aspirin for secondary prevention has far dose aspirin in those in this weight range, 10. Clinical and may have benefits beyond this pediabetes who have established judgment should be used for those at riod. Although diac testing include those with 1) typicomesaslongasatherosclerotic platelets from patients with diabetes cal or atypical cardiac symptoms and care. In adults with diabetes Although asymptomatic patients with all, so far, not shown cardiovascular $40 years of age, measurement of cordiabetes with higher coronary disease burbenefits relative to placebo. However, onary artery calcium is also reasonable den have more future cardiac events results from other new agents have for cardiovascular risk assessment. Combining both these trials, tially equal (and very low) in screened 10,142 participants with type 2 diabetes versus unscreened patients.

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This will require a court to examine the circumstances and results of domestic violence antibiotic resistance what can be done discount linezolid on line, and would allow the court to find that a party has a diminished future ability to make a living due to acts of domestic violence committed against them by the other party. Expansion of Access to Civil Orders of Protection in Family Courts the Governor has shown a longstanding commitment to protecting the safety of victims of domestic violence, including improving access to orders of protection. In 2016, the Governor signed legislation that established a pilot program in several counties to allow for the electronic filing of petitions and the issuance of temporary orders of protection by audio-visual means. Electronic filing provides emergency relief for victims who find traveling to , or appearing in, the courthouse an undue hardship or a safety risk. The Governor also signed into law a key provision that required the translation of temporary or final orders of protection and directed two pilot projects to develop solutions for language access during the family offense petition process. Yet, the legal construct of family offenses has tied civil relief for domestic violence victims to Penal Law offenses, and therefore criminal definitions of actionable behavior. This is increasingly problematic as the courts have narrowed 172 the interpretation of certain Penal Law statutes listed as enumerated family offenses and often used in domestic violence cases, and victims are required to meet the elements of these criminal offenses to get the protection they need. Governor Cuomo proposes a measure allowing Family Courts to issue orders of protection without requiring the petitioner to allege and prove a family offense was committed. The orders of protection could be issued to stop the violence, end the family disruption and/or to obtain protection. Protect Domestic Violence Victims from Gun Violence Governor Cuomo is committed to ending domestic violence and recognizes that guns are a potentially lethal ingredient in these already dangerous situations. In 2018, the Governor signed legislation to prevent individuals convicted of serious misdemeanors against a domestic partner from obtaining a gun license and to require the immediate surrender of firearms upon such a conviction. New York also requires individuals to surrender firearms if they become subject to a protective order upon a finding that they inflicted physical injury, used or threatened use of 173 a deadly weapon or behaved in a manner constituting a violent felony. To continue his commitment to protecting victims of domestic violence, Governor Cuomo proposes: fi Allow Law Enforcement to Remove Firearms from the Scene of a Domestic Dispute: Between the act giving rise to a charge of domestic violence and a conviction, abusers may continue to have access to their firearms. This measure will ensure that law enforcement has the necessary tools to protect victims from their abusers while prosecution is pending. Eliminating these additional requirements will lower the hurdles for domestic violence victims to get firearms out of the hands of their abusers. This process has many cumbersome steps, which result in many serious misdemeanors not being properly classified as disqualifying domestic violence convictions for the purposes of New York gun licensing. Further, federal law also disqualifies some individuals convicted of domestic violence misdemeanors from purchasing guns. The federal government relies on New York to flag convictions that are potential domestic violence convictions. When the process to establish a domestic relationship fails, it also impacts the administration of the federal check nationwide. This new misdemeanor crime will ensure that abusers lose access to firearms immediately upon conviction by automatically 175 designating domestic violence misdemeanors as such and eliminating a separate process to establish a domestic relationship post-conviction. Stop Reproductive Coercion Governor Cuomo has been a fierce advocate for victims of domestic violence and sexual assault with a longstanding history of signing legislation that supports the rights and protections of victims, holds domestic violence offenders accountable and proactively protects the right to access reproductive healthcare. Often the violence they endure includes sexual abuse and sexual and reproductive coercion. The Governor proposes the development of partnerships between domestic violence agencies and 176 sexual and reproductive health clinics to increase awareness of, and identify and respond to , sexual abuse and sexual and reproductive coercion. In identifying and responding to cases of sexual and reproductive coercion, the public health impacts of this type of abuse will be mitigated and survivors will get the services they need and deserve. In 2011, the Governor led the historic charge to make New York State the first large state to pass marriage equality. As both reproductive technology and notions of what constitutes a family have evolved, many same-sex couples, couples with fertility challenges, and single individuals are now able to fulfill their dreams of becoming parents. However, New York State law currently bans the practice of gestational surrogacy and creates legal uncertainty for the parents of children conceived by way of 178 reproductive technology like artificial insemination or egg donation. This year, once again, he will champion legislation that lifts the ban on gestational surrogacy. The legislation will also establish criteria for surrogacy contracts that provide the strongest protections in the nation for parents and surrogates, ensuring all parties provide informed consent at every step of the process. This legislation will ensure that New York not only joins the forty-seven other states that permit gestational surrogacy, but it will guarantee that all parties involved in the process are covered by the strongest and most robust protections in the nation. According to the Substance Abuse and Mental Health Services Administration, between 20 to 30 percent of gay and transgender people abuse substances compared to about 9 percent of the general population. In a survey conducted by Lambda Legal, more than half of lesbian, gay, or bisexual respondents, and 70 percent of transgender respondents, reported discrimination in health care services. Protecting Access to Transgender Health Care Coverage Governor Cuomo is a national leader in advancing the rights of transgender and gender nonconforming New Yorkers. As the federal government continues to rollback health care protections for transgender and gender nonconforming individuals, Governor Cuomo has made New York State a national leader in protecting this basic human right. The Department of 182 Financial Services is in the process of advancing those regulations. The Governor has also instructed the Office of Mental Health, pursuant to its new authority under the Mental Health and Substance Use Parity Law, to review and approve clinical review criteria for mental health services, directing insurers to eliminate categorical exclusions for gender affirming services so that individuals receive the medical necessity review they deserve. In 2019, the Governor also directed the Department of Civil Service to eliminate additional barriers to accessing gender-affirming procedures in the Empire Plan, the health plan option for state and local government employees and their family members. The Department of Civil Service is in the process of ensuring that all Empire Plan members are aware of their right to access comprehensive gender affirming health care. Governor Cuomo will continue to take unprecedented steps to ensure that all New Yorkers, regardless of gender identity, have access to medical care. Transgender Cultural Competency Training for New York State Employees New York is the largest employer in the State and serves as a model for best practices in service delivery and workplace diversity and inclusion. In 2011, Governor Cuomo led the charge to pass the historic Marriage Equality Act. In 2017, he established a Hate Crimes Task Force and a hotline for individuals to report bias or hate incidents. These amendments 185 will ensure that services used by New Yorkers to meet friends and significant others may not provide different protections depending on the sexual orientation or gender identity of the individuals being matched. Reducing Overrepresentation of Minority Children in Foster Care Racial bias has no place in our child welfare system, and yet, despite the best intentions of child welfare professionals, implicit bias can easily and unconsciously seep into decisions of removal and reunification within the child welfare system. He is committed to equal treatment for all families who experience the child welfare system regardless of race and ethnicity. National data identifies African-American, Hispanic/Latino, Native American, and Alaska Native children as being consistently and persistently reported to Child Protective Services, placed in out-of-home care, 186 staying in care longer, and struggling to find a permanent family connection more than children from other racial or ethnic groups. To achieve this, a caseworker does not disclose any personal and demographic information about a child or family when information about the case is being presented to key decision-makers prior to a removal being initiated.