This document summarizes the case of a 40-year-old male with type 1 diabetes who has a history of non-compliance and depression. It outlines his medical history and current health status, identifies barriers to self-care like dietary changes and medication adherence. It also reviews current research on links between depression and diabetes outcomes, and discusses counseling and behavioral therapy approaches as well as new studies exploring mindfulness and telephone-based interventions to improve diabetes management.
The role of illness perceptions and medicine beliefs in adherence to chronic ...epicyclops
Presentation given by Dr Leanne Ramsay & Dr Martin Dunbar to the West of Scotland Pain Group on 7th October 2008 at the Royal College of Physicians and Surgeons of Glasgow.
This document discusses co-occurring disorders, which are when an individual has both a mental illness and a substance abuse disorder. Approximately 50% of people with severe mental illness also have a substance abuse problem. Common disorders that co-occur include mood disorders like depression and bipolar disorder, as well as anxiety disorders. People may use substances to self-medicate their psychiatric symptoms. Effective treatment requires an integrated approach that addresses both disorders simultaneously.
directly affects cancer outcomes, some data do suggest
that patients can develop a sense of helplessness
or hopelessness when stress becomes overwhelming.
This response is associated with higher rates of death,
although the mechanism for this outcome is unclear.
It may be that people who feel helpless or hopeless
do not seek treatment when they become ill, give up
prematurely on or fail to adhere to potentially helpful
therapy, engage in risky behaviors such as drug use, or
do not maintain a healthy lifestyle, resulting in premature
death.
This document provides information about dementia care at the end of life. It begins by defining common causes of dementia like Alzheimer's disease and vascular dementia. It then discusses the natural progression of dementia and common complications that contribute to death, such as pneumonia, falls, and malnutrition. The document emphasizes that hospice can improve outcomes for dementia patients by providing better care and support at the end of life compared to traditional medical care alone.
Depression not only affects your brain and behavior—it affects your entire
body. Depression has been linked with other health problems, including
cancer. Dealing with more than one health problem at a time
can be difficult, so proper
treatment is important.
LRI05 - Self Help for Distress in Cancer - Is It Time For An RCT [Oct 2005]Alex J Mitchell
This is an academic presentation from 2005 outlining the case for a randomized controlled trial of a self-help programme to help people deal with distress and depression following the diagnosis of cancer
Depression in patients with medical conditionJunaid Saleem
Depression is commonly co-morbid with chronic medical disorders and worsens their outcomes. It decreases quality of life, functional ability, and adherence to medical treatment. It is also associated with worse health behaviors and increased medical costs. Depression independently increases mortality in conditions like diabetes, myocardial infarction, and stroke. Early identification and treatment of depression in medically ill patients can improve their quality of life and physical health outcomes. Selective serotonin reuptake inhibitors have shown benefits in reducing depressive symptoms and improving cardiac outcomes in patients with heart disease.
This document discusses end of life care decisions in the emergency department. It presents a case scenario of an 86-year-old lady presenting with shortness of breath, chest pain, and other symptoms who is admitted to the ICU and put on life support against her family's wishes. It then poses questions about the issues, ethical considerations, and medico-legal issues around end of life care decisions in the emergency department. It also provides context on tools and guidelines around identifying patients suitable for palliative versus aggressive care.
The role of illness perceptions and medicine beliefs in adherence to chronic ...epicyclops
Presentation given by Dr Leanne Ramsay & Dr Martin Dunbar to the West of Scotland Pain Group on 7th October 2008 at the Royal College of Physicians and Surgeons of Glasgow.
This document discusses co-occurring disorders, which are when an individual has both a mental illness and a substance abuse disorder. Approximately 50% of people with severe mental illness also have a substance abuse problem. Common disorders that co-occur include mood disorders like depression and bipolar disorder, as well as anxiety disorders. People may use substances to self-medicate their psychiatric symptoms. Effective treatment requires an integrated approach that addresses both disorders simultaneously.
directly affects cancer outcomes, some data do suggest
that patients can develop a sense of helplessness
or hopelessness when stress becomes overwhelming.
This response is associated with higher rates of death,
although the mechanism for this outcome is unclear.
It may be that people who feel helpless or hopeless
do not seek treatment when they become ill, give up
prematurely on or fail to adhere to potentially helpful
therapy, engage in risky behaviors such as drug use, or
do not maintain a healthy lifestyle, resulting in premature
death.
This document provides information about dementia care at the end of life. It begins by defining common causes of dementia like Alzheimer's disease and vascular dementia. It then discusses the natural progression of dementia and common complications that contribute to death, such as pneumonia, falls, and malnutrition. The document emphasizes that hospice can improve outcomes for dementia patients by providing better care and support at the end of life compared to traditional medical care alone.
Depression not only affects your brain and behavior—it affects your entire
body. Depression has been linked with other health problems, including
cancer. Dealing with more than one health problem at a time
can be difficult, so proper
treatment is important.
LRI05 - Self Help for Distress in Cancer - Is It Time For An RCT [Oct 2005]Alex J Mitchell
This is an academic presentation from 2005 outlining the case for a randomized controlled trial of a self-help programme to help people deal with distress and depression following the diagnosis of cancer
Depression in patients with medical conditionJunaid Saleem
Depression is commonly co-morbid with chronic medical disorders and worsens their outcomes. It decreases quality of life, functional ability, and adherence to medical treatment. It is also associated with worse health behaviors and increased medical costs. Depression independently increases mortality in conditions like diabetes, myocardial infarction, and stroke. Early identification and treatment of depression in medically ill patients can improve their quality of life and physical health outcomes. Selective serotonin reuptake inhibitors have shown benefits in reducing depressive symptoms and improving cardiac outcomes in patients with heart disease.
This document discusses end of life care decisions in the emergency department. It presents a case scenario of an 86-year-old lady presenting with shortness of breath, chest pain, and other symptoms who is admitted to the ICU and put on life support against her family's wishes. It then poses questions about the issues, ethical considerations, and medico-legal issues around end of life care decisions in the emergency department. It also provides context on tools and guidelines around identifying patients suitable for palliative versus aggressive care.
Physiotherapy and occupational therapy can play emerging roles in treating anorexia nervosa and bulimia nervosa. Physiotherapy includes supervised exercise to increase body fat, muscle strength, and improve mood without adverse effects. Occupational therapy promotes independence in daily activities and meaningful occupations to interrupt disordered eating patterns and develop social skills. Both physiotherapists and occupational therapists can implement treatments like group exercises, meal planning, relaxation techniques, and leisure activity exploration for patients with eating disorders. Precautions include monitoring for depression, suicide risk, and cardiac issues.
Realising the Value Stakeholder Event - Workshop:Prioritising our ‘long list’...Nesta
Workshop C - Prioritising our ‘long list’ of person and community centred approaches
Hear an update from Newcastle’s Health Economics team on interim findings from their evidence review of person and community centred care before participating in discussions to help develop criteria for prioritising which approaches the rest of the programme will ‘deep dive’ into. Criteria will be be evidence driven but also take into account ensuring a good mix of approaches and practice / grey evidence submitted to the consortium.
The lecture I gave for the Indiana University Health Joint Transplant Education and Research Lecture Series on palliative care. That's right, palliative care in transplant patients NOT at the end-of-life.
Descriptive Assessment of Depression and Anxiety Symptoms in an Outpatient Ob...ErikaAGoyer
NATIONAL PERINATAL ASSOCIATION 2014 CONFERENCE
Descriptive Assessment of Depression and
Anxiety Symptoms in an Outpatient Obstetric Clinic
Sample: Screening for Symptoms in the Context of
Substance Use Histories: The participant will be able
to: Describe psychiatric disorders during
pregnancy/postpartum, comorbidities, frequent
symptoms of depression and anxiety, a plan of care for
women with past and/or current issues with chemical
dependency and formulate recommendations for
improving mental health screening during routine
obstetric visits.
This document summarizes research on factors that predict and promote resilience in physically ill individuals. It finds that psychological factors like self-esteem, optimism, and mastery are associated with resilience. Effective coping strategies include spirituality, positive appraisal, and benefit finding. Social support from family and friends also predicts resilience. The document reviews studies on specific illnesses and interventions to increase resilience. It concludes that understanding resilience could help improve care and outcomes for physically ill patients.
ImprovingQualityofLifeforPatientswithHuntingtonsDiseaseShiloh Solis
Huntington's disease is a genetic disorder that causes movement, cognitive, and emotional issues and deteriorates over 15-17 years from onset until death. Maintaining quality of life is important as there is no cure. Nursing care involves educating families, addressing emotional needs, and focusing on maintaining function through therapies, managing symptoms like dysphagia and dysarthria, and individualizing care based on patient needs including nutrition, mobility, skin integrity, and spiritual/emotional support. Support groups and recreational activities can also help patients and families cope with the disease.
Nurses and nursing assistants play a crucial role in recognizing and treating depression in elderly patients. [1] Studies show that nurses and assistants recognize around 50% of depressive episodes in elderly patients. [2] Recognition can be improved through staff training and the use of screening tools. [3] Non-pharmacological interventions led by nurses, such as behavior therapy, exercise, music therapy and emotion-oriented care, can effectively treat depression. [4] Proper communication between nurses, patients, families and doctors is key to optimizing depression care for elderly individuals.
Dr. Elizabeth Paulk gives an excellent review of palliative care topics including end of life discussions, hospice, pain management, and family counseling.
The document discusses the benefits, burdens and harms of artificial nutrition and hydration like tube feeding in patients with advanced dementia or who are near the end of life. It finds that tube feeding does not prevent aspiration pneumonia or malnutrition, does not decrease mortality rates, and does not prevent or hasten healing of pressure sores. Tube feeding is also not shown to improve patient comfort or functional status. Instead of tube feeding, the document recommends comfort feeding by hand for patients with advanced dementia.
Ethical Issues Regarding Nutrition and Hydration in Advanced IllnessMike Aref
Be able to discuss and clarify “pleasure feeding” with patients and their families
Identify ethical issues with continuing or stopping artificial nutrition and hydration
Understand complications of artificial nutrition and hydration that are not ethically justifiable
Be able to discuss issues of self-dehydration and self-starvation
This document provides an overview of end of life care, including defining end of life care and palliative care, identifying the target population, and differentiating between palliative care and hospice care. It discusses factors that influence attitudes towards death, decision making at end of life, barriers to good end of life care, and nursing skills needed to provide palliative care. The goal is to help students understand end of life care and how to support older adults and their families during this process.
This document discusses the application of health psychology to specific physical ailments and unhealthy lifestyles. It covers coronary heart disease, pain, and cancer. For each topic, it discusses risk factors, prevention, rehabilitation, and psychological interventions. For coronary heart disease, modifiable risk factors include smoking, obesity, and sedentary lifestyle. Prevention involves a healthy diet, exercise, and treating conditions like diabetes. Rehabilitation programs encourage risk factor modification and stress management. For pain, risk factors include age, genetics, injury history, mood disorders, and stress. Prevention focuses on diet, exercise, weight management, and quitting smoking. Rehabilitation uses therapies like heat/cold, exercise, and cognitive behavioral therapy. For cancer,
Over 35% of veterans receiving VA care have been diagnosed with a mental health condition such as PTSD, depression, or substance abuse disorder. Veterans are at high risk for these issues due to the difficulties of adjusting to civilian life after deployment. The proposed community program would provide an integrated treatment approach including individual, group, and family therapy using trauma-informed models like Seeking Safety that address PTSD and substance abuse together. Case management services would also be provided to help veterans with life tasks like employment, housing, and medication management to support recovery.
Nutrition and hydration are important aspects of palliative care aimed at improving patient comfort and quality of life. Terminal illnesses can negatively impact nutritional status through issues like malabsorption and increased nutrient needs. While nutrition cannot prolong life, optimal nutrition can empower patients by enabling them to fulfill final goals and maintain dignity. A multidisciplinary approach is needed to address individual patient needs, symptoms, and preferences through oral feeding, enteral nutrition, or parenteral nutrition when appropriate. Hydration also seeks to relieve patient discomfort through careful use of oral hydration or alternatives like subcutaneous hydration.
This document provides information about hospice care services from the Midwest Palliative & Hospice CareCenter. It discusses what hospice is, the goals of comfort and quality of life for patients, where patients can receive care, eligibility which includes a prognosis of 6 months or less, the hospice care team, common questions about services, how to discuss hospice with a loved one, bereavement support services, and resources for additional information.
This document discusses integrative medicine and its principles. It defines integrative medicine as patient-centered care that uses both conventional and alternative therapies. The document outlines the history of complementary and alternative medicine in the US healthcare system. It was largely pushed out after the Flexner Report in 1910 but continued growing. The document discusses the principles of integrative medicine, which include treating the whole person, using natural therapies when possible, and emphasizing prevention and health promotion. It provides a case study of how integrative medicine helped an 18-year-old with persistent headaches by addressing physical and lifestyle factors. The document advocates for a healthcare system grounded in these integrative principles.
4. illness behavior and perceptions of illnessM.Vijaya Rani
This document discusses illness behavior and perceptions of illness. It covers several key topics:
1) How people determine when they are ill based on their ability to function and the presence of symptoms. Cultural factors can also influence symptom perception.
2) Common illness behaviors people engage in when sick like self-medication, and factors that influence help-seeking behaviors.
3) The "sick role" concept where sick individuals have both rights and obligations in society, such as being exempt from responsibilities but also expected to want to get better.
4) How illness representations, or people's beliefs and understanding about an illness, can impact their response and behaviors. Recognition of symptoms alone may not be enough to consider oneself ill
This document provides information about palliative care and comfort care at the end of life. It discusses palliative care as improving quality of life for those with life-threatening illness through pain and symptom relief. Comfort care is care that helps or soothes those who are dying with the goal of preventing and relieving suffering while respecting wishes. The document provides guidance on identifying actively dying patients, managing pain and dyspnea with opioids, and using continuous opioid infusions.
The document provides an overview of hospice care, including:
1) A brief history of hospice originating in Europe as places of refuge that provided care for the sick and travelers.
2) Hospice philosophy migrated to the US in the 1970s, with the first program opening in Connecticut in 1971.
3) Hospice care focuses on palliative care rather than curative treatment, emphasizing quality of life through pain management and symptom control for terminally ill patients.
4) An interdisciplinary team provides holistic care, support, and education for the patient and family caregivers.
The document discusses end-of-life care for pediatric oncology patients, including an overview of treatments like chemotherapy and radiation. It then covers the process of death and available palliative care resources. Key perspectives discussed include those of patients, parents, siblings, and hospital staff.
There are many advantages to cooking food at home rather than eating out. Home cooking saves a significant amount of money, allows for control over ingredients and portion sizes for better health, and teaches skills that can be used for life. The document outlines benefits like cost savings, improving health by avoiding unhealthy restaurant foods, and gaining a useful life skill. It recommends starting with a beginner cookbook and simple recipes to build cooking confidence.
Physiotherapy and occupational therapy can play emerging roles in treating anorexia nervosa and bulimia nervosa. Physiotherapy includes supervised exercise to increase body fat, muscle strength, and improve mood without adverse effects. Occupational therapy promotes independence in daily activities and meaningful occupations to interrupt disordered eating patterns and develop social skills. Both physiotherapists and occupational therapists can implement treatments like group exercises, meal planning, relaxation techniques, and leisure activity exploration for patients with eating disorders. Precautions include monitoring for depression, suicide risk, and cardiac issues.
Realising the Value Stakeholder Event - Workshop:Prioritising our ‘long list’...Nesta
Workshop C - Prioritising our ‘long list’ of person and community centred approaches
Hear an update from Newcastle’s Health Economics team on interim findings from their evidence review of person and community centred care before participating in discussions to help develop criteria for prioritising which approaches the rest of the programme will ‘deep dive’ into. Criteria will be be evidence driven but also take into account ensuring a good mix of approaches and practice / grey evidence submitted to the consortium.
The lecture I gave for the Indiana University Health Joint Transplant Education and Research Lecture Series on palliative care. That's right, palliative care in transplant patients NOT at the end-of-life.
Descriptive Assessment of Depression and Anxiety Symptoms in an Outpatient Ob...ErikaAGoyer
NATIONAL PERINATAL ASSOCIATION 2014 CONFERENCE
Descriptive Assessment of Depression and
Anxiety Symptoms in an Outpatient Obstetric Clinic
Sample: Screening for Symptoms in the Context of
Substance Use Histories: The participant will be able
to: Describe psychiatric disorders during
pregnancy/postpartum, comorbidities, frequent
symptoms of depression and anxiety, a plan of care for
women with past and/or current issues with chemical
dependency and formulate recommendations for
improving mental health screening during routine
obstetric visits.
This document summarizes research on factors that predict and promote resilience in physically ill individuals. It finds that psychological factors like self-esteem, optimism, and mastery are associated with resilience. Effective coping strategies include spirituality, positive appraisal, and benefit finding. Social support from family and friends also predicts resilience. The document reviews studies on specific illnesses and interventions to increase resilience. It concludes that understanding resilience could help improve care and outcomes for physically ill patients.
ImprovingQualityofLifeforPatientswithHuntingtonsDiseaseShiloh Solis
Huntington's disease is a genetic disorder that causes movement, cognitive, and emotional issues and deteriorates over 15-17 years from onset until death. Maintaining quality of life is important as there is no cure. Nursing care involves educating families, addressing emotional needs, and focusing on maintaining function through therapies, managing symptoms like dysphagia and dysarthria, and individualizing care based on patient needs including nutrition, mobility, skin integrity, and spiritual/emotional support. Support groups and recreational activities can also help patients and families cope with the disease.
Nurses and nursing assistants play a crucial role in recognizing and treating depression in elderly patients. [1] Studies show that nurses and assistants recognize around 50% of depressive episodes in elderly patients. [2] Recognition can be improved through staff training and the use of screening tools. [3] Non-pharmacological interventions led by nurses, such as behavior therapy, exercise, music therapy and emotion-oriented care, can effectively treat depression. [4] Proper communication between nurses, patients, families and doctors is key to optimizing depression care for elderly individuals.
Dr. Elizabeth Paulk gives an excellent review of palliative care topics including end of life discussions, hospice, pain management, and family counseling.
The document discusses the benefits, burdens and harms of artificial nutrition and hydration like tube feeding in patients with advanced dementia or who are near the end of life. It finds that tube feeding does not prevent aspiration pneumonia or malnutrition, does not decrease mortality rates, and does not prevent or hasten healing of pressure sores. Tube feeding is also not shown to improve patient comfort or functional status. Instead of tube feeding, the document recommends comfort feeding by hand for patients with advanced dementia.
Ethical Issues Regarding Nutrition and Hydration in Advanced IllnessMike Aref
Be able to discuss and clarify “pleasure feeding” with patients and their families
Identify ethical issues with continuing or stopping artificial nutrition and hydration
Understand complications of artificial nutrition and hydration that are not ethically justifiable
Be able to discuss issues of self-dehydration and self-starvation
This document provides an overview of end of life care, including defining end of life care and palliative care, identifying the target population, and differentiating between palliative care and hospice care. It discusses factors that influence attitudes towards death, decision making at end of life, barriers to good end of life care, and nursing skills needed to provide palliative care. The goal is to help students understand end of life care and how to support older adults and their families during this process.
This document discusses the application of health psychology to specific physical ailments and unhealthy lifestyles. It covers coronary heart disease, pain, and cancer. For each topic, it discusses risk factors, prevention, rehabilitation, and psychological interventions. For coronary heart disease, modifiable risk factors include smoking, obesity, and sedentary lifestyle. Prevention involves a healthy diet, exercise, and treating conditions like diabetes. Rehabilitation programs encourage risk factor modification and stress management. For pain, risk factors include age, genetics, injury history, mood disorders, and stress. Prevention focuses on diet, exercise, weight management, and quitting smoking. Rehabilitation uses therapies like heat/cold, exercise, and cognitive behavioral therapy. For cancer,
Over 35% of veterans receiving VA care have been diagnosed with a mental health condition such as PTSD, depression, or substance abuse disorder. Veterans are at high risk for these issues due to the difficulties of adjusting to civilian life after deployment. The proposed community program would provide an integrated treatment approach including individual, group, and family therapy using trauma-informed models like Seeking Safety that address PTSD and substance abuse together. Case management services would also be provided to help veterans with life tasks like employment, housing, and medication management to support recovery.
Nutrition and hydration are important aspects of palliative care aimed at improving patient comfort and quality of life. Terminal illnesses can negatively impact nutritional status through issues like malabsorption and increased nutrient needs. While nutrition cannot prolong life, optimal nutrition can empower patients by enabling them to fulfill final goals and maintain dignity. A multidisciplinary approach is needed to address individual patient needs, symptoms, and preferences through oral feeding, enteral nutrition, or parenteral nutrition when appropriate. Hydration also seeks to relieve patient discomfort through careful use of oral hydration or alternatives like subcutaneous hydration.
This document provides information about hospice care services from the Midwest Palliative & Hospice CareCenter. It discusses what hospice is, the goals of comfort and quality of life for patients, where patients can receive care, eligibility which includes a prognosis of 6 months or less, the hospice care team, common questions about services, how to discuss hospice with a loved one, bereavement support services, and resources for additional information.
This document discusses integrative medicine and its principles. It defines integrative medicine as patient-centered care that uses both conventional and alternative therapies. The document outlines the history of complementary and alternative medicine in the US healthcare system. It was largely pushed out after the Flexner Report in 1910 but continued growing. The document discusses the principles of integrative medicine, which include treating the whole person, using natural therapies when possible, and emphasizing prevention and health promotion. It provides a case study of how integrative medicine helped an 18-year-old with persistent headaches by addressing physical and lifestyle factors. The document advocates for a healthcare system grounded in these integrative principles.
4. illness behavior and perceptions of illnessM.Vijaya Rani
This document discusses illness behavior and perceptions of illness. It covers several key topics:
1) How people determine when they are ill based on their ability to function and the presence of symptoms. Cultural factors can also influence symptom perception.
2) Common illness behaviors people engage in when sick like self-medication, and factors that influence help-seeking behaviors.
3) The "sick role" concept where sick individuals have both rights and obligations in society, such as being exempt from responsibilities but also expected to want to get better.
4) How illness representations, or people's beliefs and understanding about an illness, can impact their response and behaviors. Recognition of symptoms alone may not be enough to consider oneself ill
This document provides information about palliative care and comfort care at the end of life. It discusses palliative care as improving quality of life for those with life-threatening illness through pain and symptom relief. Comfort care is care that helps or soothes those who are dying with the goal of preventing and relieving suffering while respecting wishes. The document provides guidance on identifying actively dying patients, managing pain and dyspnea with opioids, and using continuous opioid infusions.
The document provides an overview of hospice care, including:
1) A brief history of hospice originating in Europe as places of refuge that provided care for the sick and travelers.
2) Hospice philosophy migrated to the US in the 1970s, with the first program opening in Connecticut in 1971.
3) Hospice care focuses on palliative care rather than curative treatment, emphasizing quality of life through pain management and symptom control for terminally ill patients.
4) An interdisciplinary team provides holistic care, support, and education for the patient and family caregivers.
The document discusses end-of-life care for pediatric oncology patients, including an overview of treatments like chemotherapy and radiation. It then covers the process of death and available palliative care resources. Key perspectives discussed include those of patients, parents, siblings, and hospital staff.
There are many advantages to cooking food at home rather than eating out. Home cooking saves a significant amount of money, allows for control over ingredients and portion sizes for better health, and teaches skills that can be used for life. The document outlines benefits like cost savings, improving health by avoiding unhealthy restaurant foods, and gaining a useful life skill. It recommends starting with a beginner cookbook and simple recipes to build cooking confidence.
This report surveys what’s changing when it comes to how we find, cook and eat food, how we think about what we eat and how brands are marketing food. It doesn’t, however, attempt to round up everything of note in the wide world of food and beverage. Rather, it focuses on eight
of the relevant macro trends we’ve highlighted in the past few years, plus three overarching trends affecting the food category: the influence of technology, health and wellness, and foodie culture. Within these trends, we spotlight some of the things to watch we’ve been tracking.
The document provides information on various kitchen materials, utensils, and equipment commonly used in commercial cooking, including their properties and appropriate uses. It describes materials like aluminum, stainless steel, glass, and cast iron as well as tools for mixing, measuring, chopping, serving, and more. Proper care and use of each item is discussed to help chefs select and maintain the right tools for cooking efficiently and safely.
This document lists common kitchen tools and equipment including a chopping board, knife, spatula, mortar and pestle, grater, peeler, blender, microwave oven, grill, casserole, and frying pan which are all basic tools needed for preparing and cooking food in the kitchen.
10 Tips for Making Beautiful Slideshow Presentations by www.visuali.seEdahn Small
1. Know your goal | make each slide count
2. Plan it out | in some detail
3. Avoid templates | they have the uglies
4. Choose a color scheme | 4 colors, 1 accent
5. Choose a font scheme | match tone
6. Choose a layout scheme | comprehension
7. Use images (wisely) | they’re more memorable
8. 15 words per slide | this slide had 16 words
9. Play with typography | impact, interest, hierarchy
10. Don’t overdo it | white space
Hope you enjoy!
SEE MORE OF MY WORK: http://www.visuali.se
The document provides examples of standard, boring presentation templates and encourages the creation of unique, visually appealing templates instead. It emphasizes using fewer words and more images per slide, varying fonts and colors, and breaking content into multiple slides to keep audiences engaged. Inspiration sources like design blogs and galleries of infographics and slide designs are recommended for making impactful presentations that attract and impress audiences.
This presentation discusses the relationship between type 2 diabetes and depression. It finds that depression is more common in people with type 2 diabetes, with prevalence rates ranging from 10-30%. Depression is also identified as a risk factor for developing type 2 diabetes. Chronic stress may also increase the risk of depression and diabetes. While depression in diabetes often goes underrecognized and untreated, the document outlines new effective treatments such as online cognitive behavioral therapy, mindfulness therapy, and stepped care models in primary care settings.
Carter Sherman Annotated Bib. Bipolar DisorderCarter Sherman
This annotated bibliography summarizes research on the bio-psycho-social aspects of bipolar disorder. Key findings include:
1. Bipolar disorder is often associated with co-occurring mental illnesses and lower quality of life, even during stable phases.
2. Social factors like interpersonal problems, occupational issues, and early onset may predict higher suicide risk. Mortality is also elevated compared to the general population.
3. Physical health problems and sleep disturbances are more common for those with bipolar disorder. Severe mental illness increases risks of chronic health issues.
4. Men and women experience different symptoms, though rates are consistent between genders. Diagnosis and treatment can also differ based
Dr Nicassio Presents "Coping with Lupus" at Lupus LA's Annual Patient Educat...LupusNY
The document discusses future trends and challenges in managing chronic illnesses like systemic lupus erythematosus (SLE). It outlines a shift from solely biomedical models of care to biopsychosocial models that address psychological and social factors in addition to disease. Improving health-related quality of life is emphasized over just controlling disease. Developing patient skills and resilience is important for long-term self-management of SLE. Interdisciplinary collaboration integrating behavioral science and medicine is needed to best help patients.
This document discusses eating disorders, their causes and effects. Eating disorders primarily affect adolescent girls and have the highest mortality rate of all mental illnesses. They can cause many serious health risks such as heart failure, osteoporosis and gastric rupture. Current treatment options are lacking with less than 50% recovery rates. Eating disorders are complex with potential biological, familial, psychological and personality influences. They typically begin during adolescence when peer pressure and body dissatisfaction are highest.
This document discusses eating disorders, their causes and effects. Eating disorders most commonly onset during adolescence and mainly affect adolescent girls. They are associated with many health risks and have high mortality rates. Current treatment options are lacking with less than 50% recovery rates. Eating disorders like anorexia nervosa and bulimia nervosa are influenced by biological factors, familial influences, personality traits, and psychological processes. More research is needed to better understand and treat eating disorders.
Ethical consideration is important in nursing practice, especial.docxdebishakespeare
The document discusses the importance of considering a patient's ethnic and cultural background when providing nursing care, especially for patients with type 2 diabetes. It describes a Hispanic patient who was hospitalized for complications of type 2 diabetes and a chronic foot ulcer. His cultural beliefs about diabetes and fatalism impacted his self-management. The nurse considered his ethnicity and ensured culturally competent care by understanding his perspectives on diabetes causation and remedies.
Health Services Utilization Carly's Study DesignCarly Thompson
This document outlines a study examining barriers to eating disorder treatment among women. The study will use Anderson's Behavioral Model framework to identify predisposing, enabling, and need factors that influence barriers. The dependent variable is barriers to inpatient and intensive outpatient treatment. Independent variables include demographic, clinical, social, and system-related factors. The study aims to compare barriers across eating disorder subtypes to address disparities in access and utilization of treatment. Key hypotheses predict financial barriers will impact bulimia and OSFED most while shame will impact anorexia most.
There are three main types of diabetes: Type 1, Type 2, and gestational diabetes. Type 1 diabetes occurs when the immune system attacks and destroys the insulin-producing cells in the pancreas. It accounts for 5-10% of diabetes cases and treatment requires lifelong insulin administration via injections or pump. Psychological impacts of Type 1 diabetes can include depression, stress, low self-esteem, and social anxiety. Higher levels of depression, stress, and social anxiety are associated with poorer diabetes management and control. Social support from family, friends, and medical providers is important for helping adolescents cope with Type 1 diabetes.
The document discusses eating disorders, including signs and symptoms, contributing biological and psychosocial factors, and treatment options and their high costs. Eating disorders are complex illnesses affected by genetics and environment. They disrupt individuals' lives and are often comorbid with other issues like depression. Treatment includes inpatient programs, therapy, and medication, but access is limited due to high costs averaging $60,000-$100,000. Social workers can help educate about disorders and advocate for treatment access and coverage.
Ethical consideration is important in nursing practice.docxwrite22
Ethical consideration is important in nursing practice, especially when providing care to patients from diverse sociocultural backgrounds. The document discusses caring for a Hispanic patient with type 2 diabetes who had different cultural beliefs about the causes and treatment of diabetes. These included beliefs that diabetes is temporary, not identifying some types as severe, and viewing their health condition as punishment from God. Considering a patient's sociocultural background and beliefs is important for providing culturally competent, holistic care.
The document discusses an evolutionary medicine approach to mental health and resilience. It argues that existing mental health treatments are only partially effective and that a new approach is needed. Changes to our modern diets have reduced our ability to handle stress due to nutrient deficiencies. Following a diet and lifestyle aligned with our evolutionary past can help promote mental well-being by reducing inflammation and strengthening the immune system. While randomized controlled trials are still needed, studies suggest dietary interventions may help treat conditions like ADHD, autism, and violence. An evolutionary approach could revolutionize treatment and prevention of mental illness.
This document discusses an evolutionary medicine approach to mental health and resilience. It argues that existing mental health treatments are only partially effective and that a new approach is needed. Mental illnesses are linked to differences between our current lifestyle and our hunter-gatherer past, and are influenced by genes, stress, diet, and inflammation. Adopting a lifestyle focused on nutrient-dense foods, stress management, sleep, exercise and social connection could help build resilience against mental illness by better matching our biology. However, randomized trials of this evolutionary approach are still needed.
This document discusses lifestyle medicine and the formation of a lifestyle medicine interest group at UCSF. It provides background on lifestyle medicine, including its focus on using lifestyle interventions like nutrition, exercise, and stress management to treat and manage disease. It summarizes evidence that lifestyle factors account for the majority of chronic disease risk and that lifestyle changes can significantly reduce risks. The interest group aims to help members develop expertise in lifestyle medicine, practice healthy living themselves, and do outreach and coaching to others. Meetings will include discussions, speakers, and health education on various topics related to lifestyle and chronic disease.
This document provides information on chronic illness in adolescents including:
- Chronic illnesses are long-lasting health conditions that impact physical, mental, and social well-being. Examples include asthma, cancer, diabetes, and heart disease.
- Approximately 20-30% of adolescents in the US have a chronic illness, with 10-13% reporting substantial limitations. Depression and non-adherence to treatment plans are common issues.
- Several assessment tools are recommended to evaluate an adolescent's medical history, illness impact, depression, anxiety, quality of life, and treatment adherence.
- Suggested intervention strategies include cognitive behavioral therapy to challenge irrational thoughts and beliefs, develop coping skills, and improve treatment adherence.
This document discusses diabetes, including types, prevalence, risk factors, and the role of psychology in prevention and treatment. It covers:
- Types 1 and 2 diabetes, risk factors for each type, and prevalence rates globally and in Pakistan.
- Common mental health comorbidities like depression and anxiety that occur with diabetes and impact self-management. Screening tools and diagnosing psychiatric disorders in diabetic patients are discussed.
- Behavioral and psychological interventions for diabetes prevention and management, including lifestyle changes, motivational factors, problem-solving skills, and social support. Models of behavior change and common intervention strategies are outlined.
Clients Presentation Your client can make up whatever they want.WilheminaRossi174
Clients Presentation: Your client can make up whatever they want. They can be as dramatic as they want to be. Have fun with it!
Subjective Data (4 points): (Review History questions in power point and on page 534-535 of text.)
Objective Data (4 points):
Inspection: What is the shape and size of the abdomen? Any masses or pulsations upon inspection? Skin smooth? Striae, scars, lesions?
Auscultation: Bowel Sounds Present in all 4 quadrants? Hypoactive, Normoactive, etc. Any bruits upon auscultation?
Percussion: Tympany in all 4 quadrants?
Palpation: Abdomen soft, firm? Any enlarged organs? Masses? Tenderness?
Any other objective data you found important to document?
Describe 2 Actual/Potential Risk Factors (2 points):
CHAPTER 15
15.1 INTRODUCTION
Although in some cases behavioral and psychiatric/mental are grouped under the same broad
category, behavioral health problems are generally effectively treated on an outpatient basis with
combination psychotherapy and pharmacotherapy (medications). Behavioral health professionals
are licensed by the state in which they reside to practice, and they collaborate on the management
of clients’ behavioral problems. These professionals include psychiatrists, psychologists,
psychiatric nurse practitioners, social workers, family counselors, and drug/alcohol and mental
health counselors (Parker, 2002). Such chronic problems as dementia and mental retardation are
considered psychiatric/mental problems rather than behavioral.
There is a distinct interconnectedness between mental health and health in general. The WHO
defines health as, “a state of complete physical, mental, and social well-being, and not merely the
absence of disease and infirmity” (WHO, 2001b, p. 1). Mental health on the other hand is defined
as, “a state of well-being in which the individual realizes his or her own abilities, can cope with the
normal stress of life, can work productively and fruitfully, and is able to make a contribution to his
or her community … it is determined by socioeconomic and environmental factors and it is linked
to behavior” (WHO, 2001a, p. 1; WHO 2010, p. 1). For example, people are generally resilient
enough ...
Motivation - I assessed the patient’s level of motivation through interview. He often referred to his financial barriers and lifestyle difficulties (being 40 yo, unemployed, living w/parents). All of these suggest a level of depression which directly affects motivation. That, in combination with his frequent change in discussion topic) led me to believe that he was not very motivated. He had many personal rationalizations of why he ate the way he did. Goals - Although his ability to access food and medication would likely be his most important goal, the more immediate goal would be to follow a consistent carbohydrate ADA diet because this is something he can start doing immediately within his parent’s home. Through discussion with the patient, his parents seem quite supportive. Compliance - Although the patient says that he is motivated to make the changes, he would often send the conversation on a tangent and would make excuses for why he doesn’t follow his diet. I do not feel that his motivation is at a good level nor do I feel that his compliance will improve after discharge. Barriers - The patient is unemployed so financial issues are certainly of concern, both in paying for medications and purchasing food. However, he does live with his parents and often eats at least one meal per day with them. I am not aware of whether he gets unemployment or of his insurance situation, but the social workers would be able to help him sort out ways to get medications and help him get SNAP or food bank assistance. His educational level seems sufficient to understand the material, however he seems to suffer from depression which is a strong motivational barrier. May 20, 2011
As health care providers we ask DM patients to undertake quite a bit – dietary changes, exercise, self monitoring, self medicating, self injecting, and frequent visits to clinic. We educate, educate, and educate again…..yet we get such low compliance. Education is not enough, so much of self-care is influenced by cognitive function, including depression May 20, 2011
14.8 million– that’s how many people are affected by depression each year 23.5 million – that’s how many people are affected by diabetes each year 20-25% - the % of those with diabetes that experience depression 1.6-2.0 – the relative risk for experience depression in the diabetic population compared to general population Even at subclinical levels, having depression along with diabetes is associated with worse DM control and increased risk of complications. Ultimately these complications can lead to an increased risk of mortality 1.76 – relative risk of mortality in women with depression 1.71 – relative risk of mortality in women with diabetes 3.11 – relative risk of mortality in women with both depression and diabetes Clearly suffering from a combination of these conditions increases risk of mortality to a startling degree May 20, 2011
Much emphasis is placed on clinical management of diabetes, but even when patients have received repeated education, patients are often non-compliant. There must me more at work. How patients feel about their condition plays a major role. Patients with diabetes may show earlier cognitive decline or even depression; a compounding factor that occurs more frequently in diabetics than the general population. Early health behavior related studies investigated things like demographics and social characteristics and their effect on behavior, but most of these were not found to be good indicators of behavior, largely because most of them are difficult if at all possible to change. Therefore the findings of these studies were not especially helpful in designing interventions. Psychological aspects were better predictors so new theories were developed. Use of the Health Belief Model can help us understand the factors at play. If a patient is falling short in one or more of the 5 aspects of the HBM, this could lead to symptoms of depression and poor self-care. The 5 dimensions of the HBM include: perceived severity of the condition perceived susceptibility of vulnerability to the disease process perceived benefits costs/barriers cues to action (internal-symptoms or external-education). Perceived severity was found to have the biggest impact on long term regimen adherence. Perceived susceptibility was found to have the greatest impact on preventative self-care behavior Perceived benefits was found to have the greatest impact on sick-role behavior, in other words, behavior just after diagnosis Costs/Barriers was found to have the greatest impact on self-care behavior in young people, especially those transitioning from pediatric to adult care. As dietitians, we can use this information to curtail our message depending on where in the spectrum the patient falls; putting emphasis on the appropriate aspect of the HBM. The Theory of Planned Behavior is another tool that can be used to evaluate barriers to self-care. While historically used to evaluate one-time behavior decisions, Shankar et al used the TPB to predict repeated self-care in diabetes patients. The main focus of TPB is intention, how hard someone is willing to work for an end. Or more specifically, intention refers to an individual’s attitude about a behavior and their expectations of an outcome. It also refers to the individual’s perception of social pressure to perform the action whether or not they are motivated to comply with the pressure. For example, a diabetic man’s motivation to comply with pressure he receives from his wife and family to adhere to his self-care regimen. Researchers found that the saying, “past behavior is a good predictor of future behavior”, holds true. That being said, they also found that people’s intention to self-monitor was high and that most of their participants checked their blood sugar at least twice daily. In addition the researchers found that the stronger barrier to adherence was not intention or control, but perceived difficulty. In other words, they found it difficult to check their blood sugars at work or in social settings. Again, as dietitians, we need to be sensitive to the needs of each patient. Rather than more clinical education on blood sugar monitoring, programs that increase patient’s self-efficacy (overcoming perceived difficulties) would be more beneficial in the long run. When preventable diseases are diagnosed, how does blame and anger affect management? A research study by DePalma et al published in the American Journal of Health Behavior, investigated how blame and anger affect diabetes management. Their results were mixed, depending on the level of blame experienced by the subjects. Those subjects with especially high levels of anger and blame regarding their disease were less likely to maintain good glycemic control. On the other hand, they found that those individuals with low levels of blame and anger translated these emotions into responsibility for their medical maintenance and had improved glycemic control. This begged the question, should we change how our patients think about their disease? Researchers vehemently discouraged this thought process. Ultimately, researchers concluded that self-blame and anger regarding disease interfered with effective glycemic control. The researchers suggested that while much emphasis is placed on clinical control (ie education) of diabetes, not enough is done to contend with the psychological/social aspects of diabetes management. May 20, 2011
The American Association of Diabetes Educators (AADE) has found that people with diabetes have improved management when they are able to deal with psychosocial issues in their lives. In fact, they feel it is so important that it has now been included in their revised AADE-7 Self-Care Behaviors guidelines. These guidelines are: healthy eating being active monitoring taking medication problem solving reducing risk healthy coping. I am going to focus on the last of these 7 guidelines – healthy coping. Good coping behaviors include: fulfilling health care obligations expressing emotions seeking help demonstrating basic problem-solving skills physical activity being proactive demonstrating self-efficacy overcoming barriers being motivated and optimistic. There is a plethora of barriers to good coping: low social support financial stress or constraint external locus of control low problem-solving ability stressful life events low educational level low health literacy external focus poor prioritization skills lack of access to providers and diabetes educators compounding health problems perceived stigma attached to admitting an inability to cope And the DAWN study (Diabetes Attitudes, Wishes, and Needs) revealed that greater than 40% of the respondents reported low psychosocial well being. Clearly psychosocial health and coping are major concerns for those with diabetes. Currently, most assessment tools identify unhealthy coping strategies, but few target healthy coping strategies so the AADE is working on development of a tool that will focus on positive coping strategies related to the AADE7 and provide a composite score that can be shared with the patient. Any health provider from nurses, physicians, mental health professionals, dietitians, and pharmacists, can utilize this tool and others already in existence to screen for depression in their patients with diabetes. Study published just this year looked at the associations of depression with glycemic control and compliance to self-care activities in adult patients with T2DM. Specific self-care activities included taking dose on time taking dose as advised dietary restriction exercise foot care. They found a significant relationship between depression and female gender which supports the earlier statistic of increased depression and mortality in women. They also found that women were less likely to follow recommendations of exercise and more likely to have higher BMIs. Special consideration in screening and intervention should be taken with this population. The researchers found that depressed diabetic patients were less likely to adhere to all self-care factors than their non-depressed counterparts. A possible explanation offered by the researchers puts depression and poor glycemic control into a cyclic relationship. Depression and psychological stress increase sympathetic nervous system activity, inflammation, platelet aggregation, and decreased insulin sensitivity which leads to poor glycemic control, which increases the risk of complications, which increased depression. The key is to break the cycle, but how? May 20, 2011
Clearly, improved counseling for patients with diabetes is needed. Diabetes educators should be trained to assess psychosocial well-being in their patients and refer them to specialists as needed. One possible approach involves Cognitive Behavioral Therapy as part of a team approach. A 2010 case series study investigated the effect of CBT on adherence and depression (CBT-AD) in T2DM. Intervention consisted of 1 visit with a nurse diabetes educator, 2 visits with a dietitian, and 10-12 sessions of CBT-AD with a psychologist. Participants met with the nurse diabetes educator at baseline to set goals for treatment regimen: medication, self-monitoring of blood glucose, and foot care. At baseline, the dietitian performed a comprehensive assessment of self-management behavior in terms of weight loss, physical activity, blood glucose monitoring. Then the dietitian helped each participant set 2 nutrition goals and 1 physical activity goal. The second dietitian visit occurred at 6-8 weeks into the program. At this visit the dietitian and the participant evaluated the progress of the goals and collaborated on revision if necessary. The 10-12 visits with the psychologist consisted of an initial orientation visit followed by 9-11 visits called “Life Steps”. The Life Steps program worked the participants on changing their cognitions, or thoughts about their conditions. A variety of tools were used to measure adherence and depression at both baseline and conclusion of the intervention. Adherence was also monitored by use of electronic pill caps and glucometer log. HgbA1c was evaluated at both baseline and conclusion of the program. While the study had only 5 participants, all adults with suboptimally controlled T2DM despite use of oral hypoglycemics, and with depression, the results were promising. All 5 participants had an improvement in depressive symptoms. 4 of the 5 had improvements in both depressive symptoms and glycemic control. 4 of the 5 had an increase in medication adherence post intervention when compared to baseline. At baseline all participants reported difficulty with diet and at the conclusion of the study all participants reported improvement in diet and related activities. The researchers felt that the diet intervention in conjunction with the CBT was implemental in both improved depression and improved glycemic control. Researchers found that a team approach to diabetes control is the best way to improve depression and adherence in diabetic patients. We saw with the Theory of Planned Behavior that intention was less of a barrier to good self-care then perceived difficulty. It is important to make good self-care accessible to patients with diabetes, this includes in the workplace. Diabetes is considered a disability under federal employment regulations, but this does not guarantee that every person with diabetes will be protected by the Americans with Disabilities Act (ADA). Protection is determined on a case by case basis based on whether or not the individual’s condition impairs one or more major life activities. Diabetes, like other disabilities, can have an impact on an individual’s ability to perform certain jobs and a 2001 study revealed that people with diabetes earned only 72% of what non-diabetics earned and were two times as likely to be unemployed as a result of complications. Challenges in the workplace include difficulty working rotating shifts jobs requiring a significant amount of physical activity or standing for long periods of time limited time and location to self-monitor and self-medicate access to medication storage. When patients are confronted with these challenges, it can undermine their motivation, intention, and adherence to self-care regimen. Addressing these challenges with specific accommodations such as frequent breaks and rest areas, padded carpeting, flexibility to sit or stand during shift, shorter work days with extended work week, and job sharing can enhance compliance and reduce depressive symptoms. Diabetic patients who are also experiencing depression may need additional accommodations of stress reduction, stress management, or time off to attend counseling. Something important to consider, however is the disclosure of diabetes status. Counselors on the multidisciplinary team should help patients determine when it is appropriate to reveal their diabetes status. In some instances, as when the disability is visible or help from others may be required, as in unstable glycemic control, it is both necessary and beneficial to reveal status. In some instances it is not necessary and may, in fact, be harmful to disclose diabetes status, for example, during the hiring process. May 20, 2011
As we have seen, there is limited research on diabetes and depression. Cognitive Behavioral therapy has proven to be a possible treatment option, but researchers have come up with a randomized controlled trial study design focused on mindfulness. Mindfulness is defined as self-regulation of one’s attention focusing on direct experience, while adopting a curious, open, and accepting attitude towards these experiences, especially one’s psychological processes, such as thoughts and feelings. Similar “mindfulness” studies showed positive effects on patients with chronic pain and those with cancer. It has also show positive effects on patients with non-diabetes related depression and anxiety. Since diabetes patients have a unique set of circumstances to deal with; diet, physical activity, self-monitoring, and self-medicating, the researchers want to see if a mindfulness intervention will produce positive results for this population as well. The theory is that mindfulness interventions will enhance emotional well-being. Better mood – better self-care behaviors. In addition, mindfulness interventions put a considerable focus on bodily sensations. Those who become more mindful will be in better tune with their bodies signals leading to improved self-care. Dependent variables: emotional distress (depression, anxiety), quality of life, mindfulness, self-esteem, improved self management, improved glycemic control, and controlled blood pressure. Independent variable: intervention (Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy programs. 8 weekly, 2 hour sessions. Each session has a different theme, but follows the same format: exercise, discussion of exercise, discussion of previous week’s homework, discussion of week’s theme, more exercises, homework assigned, and concluding with a short meditation, poem, or relevant story. Subjects: adult men and women with either T1 or T2 DM with a score of <13 on the WHO-5 well being index. Assessment: Baseline HgbA1c and blood pressure readings are taken on initial interview. HgbA1c, and blood pressure will be assessed again at completion of intervention. HgbA1c will be reassessed at intervals following intervention until 6mos post intervention in the experimental group at which time the waitlist, control group will begin receiving intervention. Various tools will be used to measure things like stress, anxiety and depressive symptoms, mood, quality of life, self-care behavior, mindfulness, and self-esteem. These assessments will also take place periodically up to 6 mos post intervention. Challenges: Recruiting sufficient number of subjects who are willing to commit to the 8 weeks of 2hr interventions and homework 5 days per week. Researchers hope to have preliminary results available early next year. Review of interventions targeting diabetes self-management reveals that effectiveness of intervention is significantly related to duration of intervention. Many interventions would not be practical in the long term. Clearly there is a need for cost-effective on-going intervention. Proposed randomized control trial that would use automated, interactive telephone interventions to help improve self-care in diabetes patients. Subjects: 340 adults with T2DM in either experimental or control group. Dependent variable: HgbA1c, quality of life, self-efficacy, anxiety and depression, diet, physical activity, and BMI to name a few. Independent variable: automated telephone intervention. Variables would be measured at baseline and again at conclusion of intervention (24 weeks) and yet again at 12 mos post intervention. Methods: Control group is asked to continue their present management. In the intervention group, patients would phone in on a weekly basis to share their adherence to regimen and receive an education on one of 3 topics depending on the week and their circumstance. These education sessions would focus on medication, physical activity, and healthy eating. For individuals who do not have medical clearance for physical activity, their PA messages would be replaced with messages on the other topics. Likewise for those individuals who do not use medication. In addition, all participants (both experimental and control) will receive a quarterly newsletter to help maintain participation. The TLC Coordinator will call participants after their first two calls and then at weeks 6, 12, and 20 in order to resolve any issues (technical or otherwise) that the participants have experienced. TLC Coordinator will also be available to resolve issues on an as needed basis. Measurement: HgbA1c, other chemistries, height, weight, and various tools to measure self-care, anxiety, depression, etc. Information will also be collected on program costs and related to cost-effectiveness compared to other intervention strategies. Automated TLC systems have been effective in adherence to other chronic disease states, but has never been used for diabetes self-care adherence. Role of Dietitians: Be vigilant in assessing patients. Learn to recognize signs and symptoms of diabetes-related anxiety and depression. Try to determine why patients are non-compliant as opposed to re-educating, re-educating, re-educating. Know when to refer patients out to mental health specialists and therapists. May 20, 2011