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Secondly, there is no relation between the reference ranges given and the analytical method which means that using upper or lower reference limits (or multiples thereof) cannot be safely used as indicators. These laboratory factors need to be included in order to ensure equality across the nation. Screening of My laboratory performs the equivalent of 1 test for 5 of the interventions fall outside the remit of this Pathologists population every year. These will be of Surgeons al techniques in managing thyroid disease (both hormonal and benign considered as part of the question on non- of Edinburgh Nodular disease), specifically, the role of High intensity Focussed surgical management of non-malignant Ultrasound and Radiofrequency ablation. Society for Gener General There is no mention at all about laboratory factors causing Thank you for this information. Please insert each new comment in a new row Please respond to each comment Secondly, there is no relation between the reference ranges given and the analytical method which means that using upper or lower reference limits (or multiples thereof) cannot be safely used as indicators. These laboratory factors need to be included in order to ensure equality across the nation. The purpose Endocrinology additional wording to include this as it is a critically important of this brief introduction is to cover what will condition. Society for 1 18 It is important the link between thyroid and iodine is made clearly. This brief Endocrinology is worth a sentence linking the importance of iodine to thyroid in introduction is not meant to be terms of goitre and thyroid dysfunction. However the role of iodine in thyroid disease will be considered in the guideline. Society for 2 43 Isolated hypothyroxinemia has not been included here may be Thank you for this information. This is a brief Endocrinology worth including given the growing adverse associations with this. Society for 3 61 There is substantial dissatisfaction on T4 therapy (around 15%) and Thank you for your comment and Endocrinology the evidence base for T3 therapy is sub-optimal. The guideline will seek to issues with T3 costs and areas of research, T3 needs to be explicitly address the most clinically and cost indicated as a key research area. Society for 4 96 Given the importance of thyroid in pregnancy the recent trials and Thank you for your comment. Given the Endocrinology the vigorous contested debate of universal thyroid screening in breadth of the current guideline scope and pregnancy, this should be included. Please insert each new comment in a new row Please respond to each comment Obstetricians and Gynaecologists. Society for 5 119 Guidance on armour thyroid would be beneficial, given a minority of Thank you for your comment. This will be Endocrinology patients may be on this and primary care physicians as well as covered by the guideline: this has been endocrinologists would benefit from guidance here clarified in the scope.

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Identifying barriers to self-management is important when developing a management plan with the patient. Issues around cognition, physical disability, mental health, health literacy, socioeconomic constraints, location and access to services can have an impact on the ability of the person to self-manage their diabetes. Clinical context Regular physical activity improves metabolic control, reduces cardiovascular risks and can reduce the risk of developing type 2 diabetes. Two or more resistance training sessions per week (2?4 sets of 8?10 repetitions) are included in the total 210 or 125 minutes of moderate or vigorous exercise respectively. People requiring insulin or those treated with sulphonylureas need to be aware of potential delayed effects of physical activity on glucose levels in particular delayed hypoglycaemia 6?12 hours after cessation of the activity. People with diabetes need to be advised to moderate or cease their activity if they develop cardiovascular symptoms or feel unwell. Advise patients to wear correct supportive footwear especially if there is neuropathy, vascular disease, abnormal foot structure or previous foot ulcer(s), in which case the advice of a podiatrist with an interest in high-risk feet should be sought. Some activities such as hunting or other cultural activities may not be considered as ?exercise? or ?physical activity? by some Aboriginal and Torres Strait Islander people. A careful history in the context of a trusting doctor?patient relationship may bring about better understanding. Clinical context Most of the burden of disease due to poor nutrition in Australia is associated with eating too much energy-dense and relatively nutrient-poor foods, and eating too few nutrient-dense foods, including vegetables, fruit and wholegrain cereals. Enjoy a wide variety of nutritious foods from these fve groups every day: plenty of vegetables, including different types and colours, and legumes/beans fruit (consumption of fruit is not associated with risks of type 2 diabetes) grain (cereal) foods, mostly wholegrain and/or high cereal fbre varieties, such as breads, cereals, rice, pasta, noodles, polenta, couscous, oats, quinoa and barley lean meats and poultry, fsh, eggs, tofu, nuts and seeds, and legumes/beans milk, yoghurt, cheese and/or their alternatives, mostly reduced fat (reduced fat milks are not suitable for children under the age of 2 years). For women who are pregnant, planning a pregnancy or breastfeeding, not drinking alcohol is the safest option. General practice management of type 2 diabetes 27 Dietary evaluation and optimisation is a critical component in the management of type 2 diabetes. The core themes around nutrition in type 2 diabetes are eating healthily and, where appropriate, body weight (loss) and caloric management (portion control and type of food). Two other key themes are eating for cardiovascular protection and meal planning and glycaemic control. Grains in the Mediterranean region are typically wholegrain, and bread is eaten plain or dipped in olive oil. The diet recommended for a person with diabetes in the Australian Dietary Guidelines51 is qualitatively little different from the Mediterranean diet, or that recommended for all people (irrespective of whether they have diabetes, hypertension or dyslipidaemia). Meal planning and glycaemic control Some people with diabetes may require more intensive meal planning to ensure glycaemic control.

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Within this mandate, the interprofessional team should be dedicated to both maintaining the overall well being of the person with diabetes and preserving the integrity of lower extremities affected by foot ulcer(s) (Inlow et al. As offoading devices may vary greatly in cost, the selection and effectiveness of appropriate devices should be continually assessed on an individual basis to optimize quality care. While the costs of pressure redistribution devices are substantial, it is important that such costs are viewed in relation to the total cost of care for foot ulcer and increased risk of amputation (Bus et al. Nurses may advocate for strategies and ongoing funding that increase the accessibility of pressure redistribution devices for clients with foot ulcers in the hospital and community setting. These areas have been broadly categorized into practice, outcomes and health system research (see Table 7). Many of the recommendations in the guideline are based on quantitative and qualitative research evidence. Increasing the research evidence can impact knowledge that will lead to improved practice and outcomes for people who experience diabetic foot ulcers. Nursing Order Sets embedded within clinical information systems simplify this process by providing a mechanism for electronic data capture. Table 8 is based on a framework outlined in the Toolkit: Implementation of best practice guidelines (2nd ed. The uptake of knowledge in any practice setting requires more than the awareness and distribution of guidelines. Application of the guideline in any practice setting requires adaptation for the local context. Adaptation must be systematic and participatory to ensure recommendations are customized to ft the local context (Straus, Tetroe, & Graham 2009). The Registered Nurses? Association of Ontario recommends the use of the Toolkit: Implementation of Best Practice Guidelines (2nd ed. The Toolkit is based on emerging evidence that the likelihood of achieving successful uptake of best practice in health care increases when: Leaders at all levels are committed to support facilitation of guideline implementation Guidelines are selected for implementation through a systematic, participatory process Stakeholders relevant to the focus of the guideline are identifed, and engaged in the implementation process An environmental readiness assessment for implementation is conducted for its impact on guideline uptake the guideline is tailored to the local context Barriers and facilitators to use of the guideline are assessed and addressed Interventions are selected that promote guideline use Guideline use is systematically monitored and sustained Evaluation of the impacts of guideline use is embedded into the process There are adequate resources to complete the activities related to all aspects of guideline implementation the Toolkit uses the knowledge-to-action model that depicts the process of choosing a guideline in the centre triangle, and follows a detailed step-by-step direction for implementing guideline recommendations at the local level. Adapted from ?Knowledge Translation in Health Care: moving from Evidence to Practice,? S. A full version of the Toolkit: Implementation of Best Practice Guidelines (2nd ed. New editions of guidelines developed will undergo dissemination based on established structures and processes. The North-West Diabetes Foot Care Study: Incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort. Lower-extremity amputation in diabetes: the independent effects of peripheral vascular disease, sensory neuropathy, and foot ulcers. The gait and balance of patients with diabetes can be improved: a randomized controlled trial.

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The Census of Fatal Occupational Injuries is the repository for information on fatal work-related injuries. Review of entries from the last two years revealed 34 deaths, with the majority (21) relating to helicopter and plane crashes. Of the 17 surface vehicle crashes, 5 related to commuting to or from work, but details relating to time of day and fatigue were not reported. A death not listed in that site, which appear related to fatigue and resulted in a policy change, is presented on page 48. Discussions of emergency room staffing patterns generally compare 8 versus 12 hour work lengths, as busy shifts longer than 12 hours are associated with unacceptable fatigue and recognized decrements in performance (Joffe, 2006). The 12 hour threshold for declining performance of critical tasks has been confirmed in other studies of medical personnel (see Section 3). Twelve consecutive hours also is the maximum duration that the Institute of Medicine recommends nurses work during a 24 hour period (Scott et al. Flight regulations require 12 hour shifts for pilots, and both 12 and 24 hour shifts are common staffing patterns for non-pilots in the air medical community. German medical transport helicopter pilots? physiological profiles were studied during prolonged shifts, necessitated by longer summer daylight hours and more motor vehicle crashes with victims needing air transport. Findings indicated that pilots working longer hours accumulated significant fatigue, and the results led to an enforced eight hour uninterrupted sleep opportunity each day (Samel, Vejvoda & Maass, 2004). Interestingly, the investigators found that 80 percent of 24 hour and 50 percent of 12 hour non-pilot crew members had outside employment (Frakes & Kelly, 2005 & 2007), and of concern, more than half reported having arrived to work within eight hours of leaving their other job. Some did not allow naps, because they felt it might encourage arriving at work fatigued. The investigators could find no decrement in performance with the longer work hours in that short term study, and 18 hour shifts were preferred by the nurses due to lifestyle issues (Thomas et al. As stated in this Section?s outset, there is a paucity of available well done studies, and many of investigations have been done in countries other than the U. The health consequences of long work hours, inadequate sleep and disruption in daily rhythms are discussed in Section 1. For the majority of sleep deprived individuals, the problem develops insidiously, and while they might acknowledge their fatigue, they tend to discount its personal impact and consider it an issue for others, not themselves (Jones et al. The concept of adapting to sleep deprivation or training oneself to require less sleep is a myth. Better understanding of sleep and circadian physiology, plus the interest of researchers (Rosa et al. Examples of the products and services that they offer are presented on pages 69 and 70. In general, methods to minimize and cope with long work hours are divided into categories of employment-related issues and those adaptations that individuals personally can make in their working and non-working lives. Although organized into those domains, in reality, all strategies require collaboration among workers and employers.

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The interpretation of 131I scans in the evaluation of thyroid cancer, with an emphasis on false positive findings. Peptide receptor radionuclide therapy for non radioiodine avid differentiated thyroid cancer. A randomized trial of doxorubicin versus doxorubicin plus cisplatin in patients with advanced thyroid cancer. Once the thyroid remnant has been ablated and following Dynamic Risk Stratification (Chapter 2. Support and counselling may be necessary, particularly for younger patients, and in relation to pregnancy. This may include a nurse-led clinic or primary care following agreement of well defined protocols and re-referral pathways (4, D). The optimal diagnostic strategy for thyroid nodules detected during pregnancy is based on risk stratification. Radioiodine scans are contraindicated in pregnancy and during breastfeeding (4, C). Thyroid cancer discovered during pregnancy does not behave more aggressively than that diagnosed in a similar aged group of non-pregnant women. Women of childbearing age with thyroid cancer generally have an 8,9 excellent prognosis, similar to that of non- pregnant women. Surgery is the treatment of choice and may be indicated in case of rapid tumour growth or in,6 the presence of significant lymph node metastases5. Thyroidectomy may be performed safely in the second trimester when overall maternal and foetal complication rates are low. Surgery performed during the first and third trimester of pregnancy is associated with increased risks of abortion, altered organogenesis, and preterm labour and delivery,11 respectively. If thyroid cancer is diagnosed or suspected, the following options should be considered (4, D):. When a decision has been made to defer surgery until after delivery, patients may require on-going reassurance, especially if the diagnosis is made at the beginning of pregnancy. There is no evidence that previous exposure to I affects the outcomes of subsequent pregnancies and offspring, provided the recommendations are followed. The adequacy of levothyroxine treatment should be monitored approximately every 4 weeks until 16-20 weeks of gestation and at least once per trimester thereafter. This is not required in low risk patients in whom,,24,25,26 evidence of persistent disease is absent5 6 (3, D).

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