"Best tricor 160 mg, hoe hoog mag cholesterol ratio zijn".

E. Xardas, M.A.S., M.D.

Medical Instructor, University of North Carolina School of Medicine

Postprandial monitoring is associated with better glycemic control and lower risk of preeclampsia (19­21). A1C in Pregnancy maternal hypoglycemia in setting an individualized target of,6% (42 mmol/mol) to ,7% (53 mmol/mol). Due to physiological increases in red blood cell turnover, A1C levels fall during normal pregnancy (26,27). Additionally, as A1C represents an integrated measure of glucose, it may not fully capture postprandial hyperglycemia, which drives macrosomia. Thus, although A1C may be useful, it should be used as a secondary measure of glycemic control in pregnancy, after self-monitoring of blood glucose. In the second and third trimesters, A1C,6% (42 mmol/mol) has the lowest risk of large-for-gestational-age infants (25,28,29), preterm delivery (30), and preeclampsia (1,31). Taking all of this into account, a target of,6% (42 mmol/mol) is optimal during pregnancy if it can be achieved without significant hypoglycemia. The A1C target in a given patient should be achieved without hypoglycemia, which, in addition to the usual adverse sequelae, may increase the risk of low birth weight (32). Given the alteration in red blood cell kinetics during pregnancy and physiological changes in glycemic parameters, A1C levels may need to be monitored more frequently than usual. Therefore, all women should be tested as outlined in Section 2 "Classification and Diagnosis of Diabetes. Observational studies in preexisting diabetes and pregnancy show the lowest rates of adverse fetal outcomes in association with A1C,6­ 6. Clinical trials have not evaluated the risks and benefits of achieving these targets, and treatment goals should account for the risk of 14. Metformin and glyburide should not be used as first-line agents, as both cross the placenta to the fetus. The food plan should provide adequate calorie intake to promote fetal/neonatal and maternal health, achieve glycemic goals, and promote appropriate gestational weight S168 Management of Diabetes in Pregnancy Diabetes Care Volume 42, Supplement 1, January 2019 gain. As is true for all nutrition therapy in patients with diabetes, the amount and type of carbohydrate will impact glucose levels, especially postmeal excursions. Sulfonylureas systematic reviews (46,49,50); however, metformin may slightly increase the risk of prematurity. Like glyburide, metformin crosses the placenta, and umbilical cord blood levels of metformin are higher than simultaneous maternal levels (51,52). Both multiple daily insulin injections and continuous subcutaneous insulin infusion are reasonable delivery strategies, and neither has been shown to be superior during pregnancy (59). Early in the first trimester, there is an increase in insulin requirements, followed by a decrease in weeks 9 through 16 (60). Women, particularly those with type 1 diabetes, may experience increased hypoglycemia. After 16 weeks, rapidly increasing insulin resistance requires weekly increases in insulin dose of about 5% per week to achieve glycemic targets. In general, a smaller proportion of the total daily dose should be given as basal insulin (,50%) and a greater proportion (. Late in the third trimester, there is often a leveling off or small decrease in insulin requirements. Due to the complexity of insulin management in pregnancy, referral to a specialized center offering teambased care (with team members including maternal-fetal medicine specialist, endocrinologist, or other provider experienced in managing pregnancy in women with preexisting diabetes, dietitian, nurse, and social worker, as needed) is recommended if this resource is available. None of the currently available human insulin preparations have been demonstrated to cross the placenta (61­66). A recent Cochrane systematic review was not able to recommend any specific insulin regimen over another for the treatment of diabetes in pregnancy (67). Preeclampsia and Aspirin Recommendation Sulfonylureas are known to cross the placenta and have been associated with increased neonatal hypoglycemia. Concentrations of glyburide in umbilical cord plasma are approximately 70% of maternal levels (44,45). Glyburide was associated with a higher rate of neonatal hypoglycemia and macrosomia than insulin or metformin in a 2015 metaanalysis and systematic review (46). More recently, glyburide failed to be found noninferior to insulin based on a composite outcome of neonatal hypoglycemia, macrosomia, and hyperbilirubinemia. E the physiology of pregnancy necessitates frequent titration of insulin to match changing requirements and underscores the importance of daily 14.

Research gaps To date, all trials have been conducted in hospital settings, most of them referral facilities with availability of high-level care (oxygen, incubators, ventilators). The next step is to assess the effect of antenatal corticosteroids on maternal and neonatal health in lower-level facilities or home births where no specialized care is available at childbirth. Lessons learned ­ an implementation agenda In the United States, low provider use of antenatal corticosteroids 20 years ago was successfully addressed through the development of a multifaceted intervention including informing local opinion leaders, the introduction of the intervention into clinical grand rounds, chart reminders, group discussions, and audit and feedback practices (Leviton et al. The results showed no changes in the low use of antenatal corticosteroids in these hospitals (Gulmezoglu et al. Instead interventions need to be designed that combine training with appropriate supervision and clinic reminders. In low- and middle-income countries, implementation strategies that address supply-chain problems must also be prioritized to reduce occurrence of stock-outs. In recognition of the many challenges related to the uptake of proven interventions such as antenatal corticosteroids, the United Nations established a Commission on Lifesaving Commodities for Women and Children in 2012. The Commission is reviewing recommendations for addressing the supply-chain, training requirements, and other implementation barriers faced by low- and middle-income countries in their efforts to scale up antenatal corticosteroids (the aims of the Commission are described in Chapter 6) (Lawn et al. Although prospective studies that evaluate the use of risk-screening tools based on epidemiologic, demographic biomarkers and clinical indicators in routine antenatal care are still needed, there are several approaches for providing preventive care for these women. One such approach includes specialized antenatal clinics for women with evident risk of preterm birth that provide enhanced health education and more rigorous monitoring and treatment of risk factors and pregnancy complications. The evidence is scanty on such approaches in reducing the risk of preterm birth, but trials were conducted prior to the introduction of new screening tests. Administration of progesterone to prolong pregnancy in high-risk women with a history of previous preterm birth has been shown effective in preventing a recurrence of preterm birth in these women and in decreasing the prevalence of low birthweight (Barros et al. Recent guidelines and professional opinion recommend administering vaginal progesterone to women with singleton pregnancies and short cervical length to reduce preterm birth and perinatal morbidity and mortality (Berghella V. Most studies to date on the use of progesterone have been conducted in high-income countries. There is a need for evidence generation on progesterone use in resource-constrained settings including how this intervention can be scaled up at national level and the feasibility of introducing universal cervical length measurement screening. Cochrane reviews have shown small reductions in preterm birth rates with treatment interventions for pre-eclampsia such as calcium supplementation. A recent randomized controlled trial has shown promising results for the use of a cervical pessary to lower rates of spontaneous preterm birth among women with a short cervix (Goya et al. Another promising intervention in reducing the risk of preterm birth that requires further investigation is the placement of circumferential stitches on a structurally weak cervix (cerclage) (Haas, 2011; Barros et al. These interventions are only applicable to a small number of high-risk women, however, and the overall effect on general population rates of preterm birth is likely to be limited. Management of women in preterm labor to improve survival chances of the premature baby Once preterm labor has commenced, there are interventions that can prolong pregnancy and improve health outcomes and survival for the premature baby. To date, these interventions have not been designed to address the underlying mechanisms that trigger preterm labor. Interventions to prolong pregnancy include the provision of tocolytic agents that inhibit uterine contractions to suppress labor. The provision of tocolytics has been shown effective in slowing down labor, enabling the administration of antenatal corticosteroids and transfer of mother and baby to a higher-level facility where appropriate care may be available. Any use of strategies to prolong labor, including delaying cesarean birth, must be evaluated against the potential risk of continued exposure of mother and fetus to sub-optimal conditions that may result in harmful effects. Further research is needed on the short- and long-term health consequences for mother and baby from efforts to prevent preterm labor. Premature rupture of the membranes is strongly associated with infection of the amniotic membranes contributing to preterm birth and other poor fetal outcomes such as cerebral palsy and chronic lung disease. Further studies are needed, however, to investigate side effects of the treatment for the mother. American countries that educate women with healthy pregnancies about the advantages of vaginal delivery and waiting until 39 weeks to deliver should be promoted, particularly in contexts characterized by high and rising elective cesarean birth rates (Davis-Floyd, 2007; March of Dimes, 2011). Health care provider education on the adverse health outcomes of late preterm birth and of inducing delivery for non-medical reasons prior to 39 weeks has been shown to be effective in reducing preterm birth rates in some countries such as Brazil (Behague et al. Behavior and community interventions for the prevention of preterm birth Lifestyle factors including depression, intimate partner violence, smoking, substance abuse and stress are risk factors for preterm birth.

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Journalists and pro-democracy activists reported police stationed outside their homes that morning, and opposition groups reported scores of people detained, including Josй Daniel Ferrer, founder and leader of the Cuban Patriotic Union, the main opposition party and largest and most active pro-democracy group on the island. Arbitrary Detention and Short-Term Imprisonment the government continues to employ arbitrary detention to harass and intimidate critics, independent activists, political opponents, and others. From January through August 2020, there were 1,028 arbitrary detentions, according to the Cuban Human Rights Observatory, a Madrid-based human rights organization. In some cases, detainees are released after receiving official warnings, which prosecutors can use in subsequent criminal trials to show a pattern of "delinquent" behavior. Detention or the threat of detention is often used to prevent people from participating in peaceful marches or meetings to discuss politics. Police or state security agents routinely harass, rough up, and detain members of the Ladies in White (Damas de Blanco)-a group founded by the wives, mothers, and daughters of political prisoners-before or after they attend Sunday mass. In May, activist and lawyer Enix Berrio Sardб was detained for violating Covid-19related movement restrictions, when he was presenting a constitutional challenge to Decree-Law 370/2018. Freedom of Expression the government controls virtually all media outlets in Cuba and restricts access to outside information. Cuba has the "most restricted climate for the press in the Americas" according to a 2019 Committee to Protect Journalists report. A small number of independent journalists and bloggers manage to publish articles, videos, and news on websites and social media, such as Twitter and Facebook. The government routinely blocks access within Cuba to many news websites and blogs. In 2019, before a flawed referendum that endorsed a new constitution, it blocked several news sites seen as critical of the government, including 14ymedio, Tremenda Nota, Cibercuba, Diario de Cuba, and Cubanet. The high cost of-and limited access to-the internet prevents all but a small fraction of Cubans from reading independent websites and blogs. In 2019, the government issued new regulations allowing importation of routers and other equipment and the creation of private wired and Wi-Fi internet networks in homes and businesses. In July 2019, Decree-Law 370/2018, on the "informatization of society" took effect, prohibiting dissemination of information "contrary to the social interest, morals, good manners and integrity of people. In March, journalist Camila Acosta was fined in connection with three Facebook posts, including a meme of Fidel Castro. Between February and September, Cuban authorities harassed Youtuber Ruhama Fernбndez, who has published videos critical of the government. Authorities repeatedly summoned her for police interrogation and denied her a passport. In April, after summoning Fernбndez to a police station, officials told her the harassment would cease if she stopped criticizing the government. In September, she received an anonymous phone call threatening to "finish" her off. Between September 2019 and March 2020, the artist Luis Manuel Otero Alcantarб was detained at least 10 times, often without charge, for performance art pieces in which he wore the Cuban flag while going about daily activities. In March 2020, Law 128/2019, the National Symbols Law took effect, restricting use of the Cuban flag, seal, and national anthem. They do not benefit from due process guarantees, such as the right to fair and public hearings by a competent and impartial tribunal. In February, a judge in Santiago convicted Josй Daniel Ferrer, of the Cuban Patriotic Union, of assault and kidnapping in what activists say was an irregular trial. In April, after six months in pretrial detention, he was sentenced to four years of house arrest. In April 2020, pro-democracy activist and opposition party member Maikel Herrera Bones was arrested after protesting power cuts in his neighborhood and arguing with a police officer. He was initially charged with disobeying orders, but a week after he was detained authorities increased the charge to "assault. In September, Herrera told another activist that officials said they would provide proper medical treatment if he stopped complaining about abuses in the prison. Travel Restrictions Since reforms in 2013, many people who had previously been denied permission to travel have been able to do so, including human rights defenders and independent bloggers. The reforms, however, gave the government broad discretionary power to restrict the right to travel on grounds of "defense and national security" or "other reasons of public interest.

In February and June, in two separate trials, courts issued guilty verdicts, with prison terms ranging from five to 18 years, against nine defendants for alleged involvement in "Network," which prosecutors claimed was a terrorist organization. The judges accepted testimonies by secret witnesses and allegedly rigged evidence. In August, seven defendants were convicted for establishing an "extremist organization," New Greatness. Torture complaints by one of the defendants were dismissed without a full investigation. One of them refused to plead guilty and has been in pretrial detention since summer. Russian authorities continued to prosecute people over alleged involvement in Hizb-ut-Tahrir (HuT), a pan-Islamist movement that seeks to establish a caliphate but denounces violence to achieve that goal. In February, 11 defendants in two separate military trials received prison sentences ranging from 11 to 23 years. In September, in a separate case, the Supreme Court upheld sentences ranging from 10 to 24 years for 21 men. At least one of the convicted alleged he had been tortured to extract a confession. Five more men were detained over alleged involvement in HuT in November in Tatarstan. The women documented their injuries and filed a police report, describing the attacks as work-related. In September, a video circulated on social media showing 19-year-old Salman Tepsurkayev being forced to penetrate himself anally with a glass bottle in retaliation for "spread[ing] lies" about Chechen authorities. At time of writing, he remains disappeared and authorities have not opened an investigation. A prominent Chechen separatist politician in exile, Akhmed Zakaev, made a statement condemning the torture and expressing support of 1Adat. Counterterrorism Courts issued guilty verdicts in several terrorism or extremism cases marred by allegations of torture, dubious expert analysis, and reliance on secret witnesses. At least eight people are currently serving prison terms of up to six years, while 417 remain under criminal investigation, and 35 are in pretrial detention. Authorities arrested at least four people for supposed affiliation with Nurdzhular, a group of followers of the late Turkish theologian Said Nursi, banned as extremist in 2008, even though it has no history of incitement or violence. Experts repeatedly questioned the existence of such an organization in Russia and stated that the works of Said Nursi do not contain any extremist views. Yevgeniy Kim, stripped of his Russian citizenship in 2019 following his prison sentence on charges of alleged involvement with Nurdzhular, remained in deportation custody. An official representative of the indigenous peoples of the North expressed concern that the spill could affect access to food for local indigenous peoples who rely on fishing and hunting. In July, authorities adopted a new law that exempts contractors from carrying out environmental impact assessments for all "transportation infrastructure modernization projects. In January, after more than a year of continued protests against the construction of a waste dumping site in Shiyes, in Arkhangelsk region, a court ruled the construction illegal. The contracting company lost an appeal against the ruling in October, but even before the verdict had announced it would cancel the project and restore the land by the end of the year. However, authorities did not drop charges against local activists who had been beaten, detained, prosecuted, and fined for protesting the illegal construction. After weeks of protests in Bashkortostan against what local activists said was destructive limestone mining, authorities granted the area protected status and construction stopped. Authorities did not drop charges against peaceful protesters who suffered police brutality, detention, fines, and prosecution. At time of writing, at least 39 current or rejected asylum seekers remained in what amounts to indefinite detention in Russia. A biracial Russian vlogger who discussed racism and racist violence in Russia faced threats and online bullying. Migrants continued to encounter racial profiling, mass arbitrary detentions, police brutality, and xenophobia. Some Russian officials falsely claimed that crime by migrants had risen in the wake of the economic downturn caused by the pandemic. The draft law on domestic violence, introduced in December 2019, fell short of providing a comprehensive definition of domestic violence. It also failed to address several issues crucial to ensuring effective protection for survivors.