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While we appreciate TennCare will only be analyzing compliance on a 6-month process initially diabetes insipidus dogs buy amaryl 1 mg online, it is unclear how this process will continue once a person is initially removed from Medicaid coverage for non-compliance blood glucose monitor optium xceed generic amaryl 4mg on-line. Additional clarification on this process is needed to determine the exact impact to providers central diabetes insipidus definition generic amaryl 1 mg fast delivery, however diabetes type 1 and 2 discount 4mg amaryl mastercard, the current information provides detail to recognize this will add significantly to the overhead operating costs of our rural providers not to mention the uncompensated care costs for individuals that lose coverage and seek care in rural emergency departments. Impact to Rural Medicaid Beneficiaries Rural areas of Tennessee have unique challenges in relation to the implementation of Medicaid work requirements that need to be taken into consideration when rolling out a program change of this type. These include access to employment, internet connectivity, transportation and childcare. Another notable fact, is all of the counties with the highest rates of unemployment are rural. The information presented in January of 2018 is important in that it highlights the portion of the year where seasonal employment opportunities are at their lowest. This is important to note as seasonal employment makes up a large portion of the work opportunities in our rural areas. It also highlights the volatility in access to stable employment in rural Tennessee. Another issue in our rural areas is access to Community Service (volunteering) in approved settings. The draft amendment stops short of providing any information on what would be included in the definition of "approved settings". It is also recommended that a survey be completed of our rural counties on the availability of volunteer sites that would allow an individual to comply with the requirements of the proposed draft. For example, only 2 percent of urban citizens do not have access to 25/3 broadband connectivity in Tennessee compared to 34 percent of rural citizens. Although the draft is largely silent on how the self-reporting will be deployed, it is highly probable that is will be disproportionally burdensome on rural Medicaid enrollees to comply with this provision on a monthly basis. Penalties should be waived for rural areas that are unable to comply with monthly compliance deadlines. Rural areas of our state completely lack any type of public transportation infrastructure. A review of the Tennessee Poverty Rate by County reflects that 42 counties in Tennessee have at least 20% poverty rate if not higher. Without the proper social supports, like access to transportation, individuals will not rise out of poverty, they will simply lose their healthcare coverage for non-compliance with this proposed work requirement, thus sinking them deeper into poverty. A second barrier to satisfying these requirements is access to affordable childcare. Obviously, young children under age 10 should not be left without supervision at any time. In most cases, older teenage children may be left alone for short periods of time. In its first two years, the program has shown promise and has generated strong participation among enrollees, likely because the state has engaged in intensive outreach, offered meaningful services, and provided trainings to service providers and partners in how to meet the needs of low-income Medicaid enrollees. Due to the fact that TennCare cannot forecast the expected impact on enrollment these changes will have, we encourage the Bureau to proceed slowly without penalties until a greater understanding of the potential impact can be assessed. We strongly encourage a period of in-depth education of Medicaid beneficiaries and a grace period where penalties will not be implemented for at least the first-year post rolling out these proposed requirements. Sharon Cox Sent from my iPad 1 Jonathan Reeve From: Sent: To: Subject: Rakhit, Shayan <shayan. Tenncare Feedback on Amendment 38 Dear Tenncare, Does the State of Tennessee and Tenncare have a plan to compensate safety net hospitals for the increase in uninsured Tennesseans seeking care at safety net hospital emergency departments, which is required by the Emergency Medical Treatment and Active Labor Act, the federal law signed by Ronald Reagan in 1986? Safety net hospitals, such as Vanderbilt University Medical Center, operate on razor thin margins and thus are dependent on as many funded patients as possible, of which ensuring as many insured low-income Tennesseans as possible. Amendment 38 will reduce the number of insured low-income Tennesseans, resulting in a financial loss to safety net hospitals, such as Vanderbilt University Medical Center, for which all Tennesseans, rich or poor, rely upon, including members of the Tennessee Legislature and employees of the State of Tennessee. Will the State of Tennessee make safety net hospitals, such as Vanderbilt University Medical Center, financially whole for the effective reductions in revenue that it is proposing with Amendment 38?

Because of the possibility of progression diabetes type 2 losing too much weight buy generic amaryl 2 mg online, reversible causes are regularly sought though very rare diabetes insipidus serum levels cheap 2mg amaryl visa. Depersonalization is a very common symptom in the general population and may contribute to neurological presentations described as dizziness diabetes mellitus symptoms urine cheap amaryl 1 mg with visa, numbness diabetes symptoms in type 1 effective amaryl 2mg, and forgetfulness, with the broad differential diagnoses that such symptoms encompass. Such self-induced symptoms may occur in the context of meditation and self-suggestion. Cross References Derealization; Dissociation Derealization Derealization, a form of dissociation, is the experience of feeling that the world around is unreal. Cross References Alien hand, Alien limb; Intermanual conflict Diamond on Quadriceps Sign Diamond on quadriceps sign may be seen in patients with dysferlinopathies (limb girdle muscular dystrophy type 2B, Miyoshi myopathy): with the knees slightly bent so that the quadriceps are in moderate action, an asymmetric diamondshaped bulge may be seen, with wasting above and below, indicative of the selectivity of the dystrophic process in these conditions. Cross Reference Calf head sign Diaphoresis Diaphoresis is sweating, either physiological as in sympathetic activation. Diaphoresis may be seen in syncope, delirium tremens, or may be induced by certain drugs. Anticholinergics decrease diaphoresis but increase core temperature, resulting in a warm dry patient. Cross Reference Hyperhidrosis Diaphragm Weakness Diaphragm weakness is a feature of certain myopathies, such as acid maltase deficiency, and of cervical cord lesions (C3­C5) affecting phrenic nerve function. Forced vital capacity measured in the supine and sitting positions is often used to assess diaphragmatic function, a drop of 25% being taken as indicating diaphragmatic weakness. The spatial and temporal characteristics of the diplopia may help to ascertain its cause. Diplopia may be monocular, in which case ocular causes are most likely (although monocular diplopia may be cortical or functional in origin), or binocular, implying a divergence of the visual axes of the two eyes. With binocular diplopia, it is of great importance to ask the patient whether the images are separated horizontally, vertically, or obliquely (tilted), since this may indicate the extraocular muscle(s) most likely to be affected. Whether the two images are - 108 - Diplopia D separate or overlapping is important when trying to ascertain the direction of maximum diplopia. The effect of gaze direction on diplopia should always be sought, since images are most separated when looking in the direction of a paretic muscle. Conversely, diplopia resulting from the breakdown of a latent tendency for the visual axes to deviate (latent strabismus, squint) results in diplopia in all directions of gaze. Examination of the eye movements should include asking the patient to look at a target, such as a pen, in the various directions of gaze (versions) to ascertain where diplopia is maximum. Then, each eye may be alternately covered to try to demonstrate which of the two images is the false one, namely that from the non-fixing eye. Manifest squints (heterotropia) are obvious but seldom a cause of diplopia if long-standing. Latent squints may be detected using the cover­uncover test, when the shift in fixation of the eyes indicates an imbalance in the visual axes; this may account for diplopia if the normal compensation breaks down. Transient diplopia (minutes to hours) suggests the possibility of myasthenia gravis. Divergence of the visual axes or ophthalmoplegia without diplopia suggests a long-standing problem, such as amblyopia or chronic progressive external ophthalmoplegia. Cross References Motor neglect; Neglect Disc Swelling Swelling or oedema of the optic nerve head may be visualized by ophthalmoscopy. It produces haziness of the nerve fibre layer obscuring the underlying vessels; there may also be haemorrhages and loss of spontaneous retinal venous pulsation. Disc swelling due to oedema must be distinguished from pseudopapilloedema, elevation of the optic disc not due to oedema, in which the nerve fibre layer is clearly seen. The clinical history, visual acuity, and visual fields may help determine the cause of disc swelling. Recognized causes of disc swelling include · Unilateral: Optic neuritis Acute ischaemic optic neuropathy (arteritic, non-arteritic) Orbital compressive lesions. The disinhibited patient may be inappropriately jocular (witzelsucht), short-tempered (verbally abusive, physically aggressive), distractible (impaired attentional mechanisms), and show emotional lability.

Either way diabetes symptoms feeling hot safe amaryl 3mg, a sharp diabetes medications help weight loss amaryl 1mg fast delivery, ongoing increase in global methane concentrations was not predicted by the future greenhouse gas scenarios that were incorporated into the targets of the Paris Agreement diabetes mellitus hereditary best 3 mg amaryl. If the current increase continues diabetes mellitus exercise generic amaryl 2mg overnight delivery, the goals of that treaty could be out of reach. If it thaws, microbes turn the carbon contained in the soil into carbon dioxide and methane. Because such a vast amount of carbon is held in permafrost, warming Arctic temperatures may release a large pulse of climate-destabilizing methane and so trigger an uncontrolled positive feedback loop. A study by an international team looked at the fate of permafrost under different scenarios of greenhouse gas mitigation, including some in which no progress is made toward decreasing fossil fuel-based emissions and others in which the targets of the Paris Agreement are met. In their analysis, the team determined the highest level of natural methane emissions that can be released from the Arctic by 2100. This level is considerably lower than likely anthropogenic methane emission levels over the same time period, which indicates that human-made emissions can be reduced sufficiently to limit methane-causing climate warming by 2100 even if the permafrost undergoes an uncontrolled emission feedback-but only if a committed, global effort to reduce fossil fuel use takes place very soon. Methane emissions from the Marcellus Shale in Southwestern Pennsylvania and Northern West Virginia based on airborne measures. Very strong atmospheric methane growth in the four years 2014-2017: Implications for the Paris Agreement. Tracing the climate signal: Mitigation of anthropogenic methane emissions can outweigh a large Arctic natural emission increase. Without pipelines to bring the gas to burner tips, and in order to maintain the rapid pace of oil drilling, operators simply waste the gas-worth more than $1 million per day-by burning it off in flare stacks. Flaring permits are limited to 45 days but are now routinely extended for up to six continuous months. The report found that forests on federal lands can offset some of these emissions but only by 15 percent. Fossil fuels are extracted from public lands in 28 states with more than half the total carbon emissions coming from Wyoming. They examined why different methods of accounting for methane emissions from natural gas drilling sites vary so widely across the United States. The study revealed spikes of high emissions that occur during daytime maintenance operations, as when, for example, liquids are being removed from a well and natural gas is freely vented into the air for the duration of that process. The high temporal variability and episodic nature of methane emissions likely explain the persistent gap between the two accounting methods and mean that researchers who attempt to determine how much methane is escaping from drilling and fracking operations require "detailed activity data, unfettered and unbiased site access, and timeresolved operations data. Federal lands greenhouse gas emissions and sequestration in the United States-Estimates for 2005­14. An international research team investigated methane emissions there with the intent of distinguishing between methane from fossil fuel sources and methane arising from livestock, wetlands, and agriculture. Using both ground and aircraft measurements, the researchers determined that emissions from oil and gas operations account for 20 percent of regional methane, with the remainder from biogenic sources. That figure for fossil fuel sources is, nevertheless, ten times higher than the 1. Ground-based measurements at extraction, processing, and storage sites found low emission rates compared to gas production facilities in the United States. The team also found that emissions from pilot lights constitute a significant fraction as do flames in domestic hot water heaters. They found that the individual well pads that emitted methane in 2014 were far more likely to be still emitting in 2015 than would be expected by chance alone. The reasons for this persistent leaking were not identified but potentially 958 Vaughn, T. Temporal variability largely explains top-down/bottom-up difference in methane emission estimates from a natural gas production region. This study combined on-the-ground measurements of leaks at selected facilities (bottom-up methods) with data collected from the atmosphere via aircraft (top-down methods). Using satellite measurements and isotopic analysis, the team showed that methane from biomass sources, such as fires, decreased over the time period 2001-2016 while fossil fuel sources of methane increased. They compared these results to emissions reported by the industries themselves, as part of an accounting system that requires operators to report flaring and venting volumes, and found large discrepancies. Based on the amounts of methane and ethane detected in the atmosphere above the oil and gas fields, the reported industry emissions in this region should be 2.

Impact of an historic underground gas well blowout on the current methane chemistry in a shallow groundwater system blood glucose greater than 400 amaryl 4 mg otc. Energy industry legacy: Hundreds of abandoned wells leaking methane in Alberta communities definition of uncontrolled diabetes mellitus cheap 1 mg amaryl with visa. Mobility and persistence of methane in groundwater in a controlled-release field experiment diabetic zucchini banana bread recipe amaryl 3 mg line. Methane leaks from energy wells affects groundwater diabetic diet kit buy 2mg amaryl with amex, travels great distances, study confirms. Using new field measurement and data mining techniques, a Stanford University-led team investigated gas leaks at 88 inactive wells in Pennsylvania in an attempt to identify the characteristics of these "super-emitters. Well plugging does not always reduce methane emission, especially when the wells are vented. In many areas with extensive coal layers, decommissioning requirements for wells included mandatory venting. Using comprehensive databases, the team also estimated the number of abandoned wells in Pennsylvania to be between 470,000 and 750,000, considerably more than previous estimates of 300,000 to 500,000. According to a Bloomberg investigation, "This puts Pennsylvania among states such as California, Texas, Ohio, Wyoming and Colorado confronting the environmentally catastrophic legacy of booms as fracking and home development expand over former drilling sites. As the number of fracked wells increases, so does the chance they might interact with lost wells. In most states there is no requirement for homeowners to be notified about abandoned 853 Malewitz, J. Identification and characterization of high methane-emitting abandoned oil and gas wells. Stanford study of abandoned oil and gas wells reveals new ways of identifying and fixing the worst methane emitters. A builder who worked in the oil and gas industry for decades and suffered cardiac arrest when methane from an abandoned well he was inadvertently working atop exploded, said that there were "no signs" that a well was there. Thirty percent of the wells had methane at the soil surface that was significantly higher than their control samples in nearby fields. Thirty-nine percent of well sites had significantly lower surface soil methane than their respective controls. Researchers suggested several explanations for the latter results, including replaced soils. Fractures in the surrounding rock may connect to existing unused oil and gas wells in the area during fracking processes, thus providing a pathway for methane to migrate to the surface. The study used a mathematical model based on the large part of southern New York State underlain by the Marcellus Shale, incorporating "the depth of a new fracturing well, the vertical growth of induced fractures, and the depths and locations of existing nearby wells. Density of nearby abandoned wells was the largest factor, and researchers pointed out the continuing problem of undocumented abandoned wells. Potential of hydraulically induced fractures to communicate with existing wellbores. Dirty pipeline: Methane from fracking sites can flow to abandoned wells, new study shows. In the past year alone, the number of orphaned wells in Alberta increased from 162 to 702. At the current rate of work, deconstructing the inventory of wells abandoned just in the past year alone will be a 20year task. Fish and Wildlife Service documented 5,002 wells located on National Wildlife Refuge System units, in addition to 1,339 miles of pipeline. Almost half of the wells were inactive, while onethird were active and the remainder either plugged and abandoned or with status unknown. Subterranean temperatures and temperatures, along with well depth, are all variables that can influence leakage potentials of abandoned wells. The leakage potential of wells drilled prior to 1960 is moderate to high, and plugged wells, as well as unplugged wells, can leak. The authors note that cement plugs are imperfect barriers that can develop defects that allow fluids to flow through gaps between the plug and surrounding hole, through pores or fissures within the plug itself, or directly through cracks in the well casing.