By J. Orknarok. Goucher College. 2019.

After two years of service order januvia 100mg with amex, mothers reported improved parenting efficacy buy generic januvia 100mg online, decreased parenting stress order genuine januvia on-line, more use of non-violent discipline cheap januvia 100 mg line, better linkage with pediatric care, as well as decreased injury due to partner violence in the home, as compared with a control group. Among these are projects to develop screening tools for identifying behavior problems in preschool children, to test the effectiveness of research-based classroom interventions for very young children with serious disruptive behavior problems, and to assess the mental health needs of this vulnerable population. Recent studies have indicated that between 70 and 80 percent of children with diagnosable mental disorders who receive services are served within the school system, primarily by school psychologists and guidance counselors. The NIMH has supported many projects that seek to develop, establish, and improve school-based mental health service delivery systems. These projects range from broad programs intended to enhance the social and problem solving skills of all students, to highly specific programs designed to treat children already showing symptoms of mental health problems. Programs also range from those that intervene at multiple levels, including the child, parents, peers, and teachers, to those that focus solely on the child. For example, research is aimed at developing techniques for teachers to manage disruptive students. Several strong, multi-faceted programs that aim to prevent severe and persistent conduct problems in children have been launched. The Families and Schools Together (FAST) Track Program is a multi-faceted, multi-year program designed for aggressive children in kindergarten starting at age 6. A four-site study in North Carolina, Pennsylvania, Tennessee, and Washington, the program involves working with the child, the family in their home, and school system, including teachers. Preschool children at high risk were identified at 55 different schools. These children were randomly assigned for intervention or no intervention. The children initially enrolled in the study are now young adolescents. An evaluation of FAST TRACK indicated that by the third grade, students who took part in the program showed less oppositional and aggressive behavior and were less likely to require special education services than students who did not take part. The Linking the Interests of Families and Teachers (LIFT) Program (in Oregon) is a 10-week intervention created for children and families who are at risk for the development of conduct problems due to residence in neighborhoods characterized by high rates of juvenile delinquency. The LIFT Program is a multi-component intervention that includes parent training, social skills training, a playground behavioral program, and regular communication between teachers and parents. Following program participation, students engaged in significantly less aggressive behaviors on the playground, parents demonstrated fewer negative behaviors during family problem-solving activities, and teachers reported improved student social behavior and peer interactions. Three years following the intervention, students who received the program were less likely to engage in consistent alcohol use, less likely to have troublesome friends, and less likely to have been arrested for the first time than students who did not receive the program. Students were also less likely to demonstrate inattentive, impulsive, overactive, and disruptive behaviors in the classroom than students who did not receive the program. Programs have also been initiated which seek to enhance the skills and knowledge of all children in order to decrease their risk of future emotional and behavioral problems. NIMH has sponsored the Promoting Alternative Thinking Strategies (PATHS) Curriculum, based in Washington state, which teaches children about self-control, understanding emotions, and problem solving. The PATHS curriculum has been evaluated using students in both regular education and special education classrooms. Students who received the PATHS curriculum demonstrated better knowledge of emotions than children who did not receive the curriculum. This emotional knowledge is thought to underlie the development of necessary social skills such as friendship development and maintenance, anger management, conflict resolution, and appropriate problem solving. NIMH research is investigating promising and successful interventions to prevent and treat adolescent depression, which often coexists with conduct problems, a combustible mix that can result in violence, both against self and others. Several NIMH projects focus on determining whether cognitive therapy techniques that have been found to be effective for treating depression in adults can be applied to prevent depression in adolescents. Such research tests, among other things, the effects of after-school programs, which are based on cognitive therapy and social problem-solving techniques and delivered by school staff. Findings from this type of research are mixed, with more intensive interventions appearing to have at least initial effects of reducing or preventing depressive symptoms. Additional work is needed to determine the optimal length and intensity of interventions as well as approaches for sustaining their effects. For example, the Coping with Stress Course was designed to prevent the onset of depressive disorders among adolescents who report high levels of depressive symptoms. With programs in Oregon, Maryland, and Ohio, this group course teaches adolescents cognitive skills to identify and challenge negative or irrational thoughts and beliefs that may contribute to the development of depression. Evaluation showed that the course was successful in reducing the number of cases of depressive disorder among adolescents at risk. In fact, twice as many students in the no-treatment group developed a depressive disorder than in the treatment group. Students in the treatment group also reported fewer depressive symptoms and better adjustment than students in the untreated group. However, with the passage of time, differences between the treatment and no-treatment groups decreased. Other projects are testing the effects of pharmacological and psychosocial treatments for youth with depression (aged 12-17 years). Going beyond the effects of treatment on symptoms of depression, this research also focuses on the impact of the interventions on functioning in school, at home, and in the community. It is important in evaluating interventions for delinquents to document what has not worked, as well as what has. For example, group-home approaches that pool delinquent youth together will, in some cases, exacerbate and escalate youth violence. Even promising interventions for delinquent youth can be overwhelmed by the negative effect of grouping such youth together. This research finding has led to two highly successful treatment models for serious offending delinquents. One is multisystemic therapy (MST), in which specially trained therapists work with the youth and family in their home, with a particular focus on changing the peers with whom the youths associate. MST therapists identify strengths in the families and use these strengths to develop natural support systems and to improve parenting. Specific interventions are individualized to the family and address the needs of the child, family, school, peers, and neighborhood. Multiple, rigorous outcome evaluations have demonstrated the efficacy of this approach, and an independent cost-benefit analysis found that this model had a very high cost-benefit payoff. Although a number of states are now attempting to implement this model, the majority of programming for delinquent youth is based on models that bring together youth with problem behavior, rather than target separation of youth from problem peers. This model offers a community-based intervention for serious and chronic offending delinquents. Therapeutic foster parents are carefully selected and supported with research-based procedures for working with serious and chronic delinquents in their homes. This intervention results in fewer runaways and fewer program failures than the usual placement in group homes is less expensive, and is dramatically more effective in reducing delinquency than traditional group homes. The Foster Family-based Treatment Association, developed under NIMH leadership, now has some 400 members across the U. As important as the problem of violence is, there will be no quick, inexpensive, and fail-safe solution. Recent years have witnessed a strong growth in our understanding of the risk factors and processes that contribute to and shape child and adolescent antisocial behavior. Yet gaps remain in our scientific understanding of how child, family, school/community, and peer factors interact, and which are the most appropriate targets for prevention and early intervention in different settings. We are also learning that being "at risk" does not doom any one child to become violent; conversely, the apparent absence of certain risk does not necessarily render any one child immune from problem behavior. Successful programs that produce long-term sustained effects may need to involve long-term intense interventions to target the multiple factors that can lead to negative outcomes such as family conflict, depression, social isolation, school failure, substance abuse, delinquency, and violence. The fundamental premise of some of these interventionsCwhich separate youth with problem behaviorsCchallenges the policies, programs and procedures that currently bring problem youth together. Continued research is needed to determine the most appropriate targets for prevention and early intervention that will produce lasting change. Answers are emerging about which programs are most successful, but assessments need to be made about their costs, as well as if they will work for all groups of children and adolescents. The NIMH is committed to encouraging and supporting this research, and has a long and enduring history of support for research and research training on violence.

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Use of Tolinase must be viewed by both the physician and patient as a treatment in addition to diet and not as a substitute for diet or as a convenient mechanism for avoiding dietary restraint discount 100 mg januvia free shipping. Furthermore discount 100mg januvia, loss of blood glucose control on diet alone may be transient thus requiring only short-term administration of Tolinase purchase 100 mg januvia with amex. During maintenance programs cheap januvia 100 mg visa, Tolinase should be discontinued if satisfactory lowering of blood glucose is no longer achieved. Judgments should be based on regular clinical and laboratory evaluations. In considering the use of Tolinase in asymptomatic patients, it should be recognized that controlling the blood glucose in noninsulin-dependent diabetes has not been definitely established to be effective in preventing the long-term cardiovascular or neural complications of diabetes. Tolinase Tablets are contraindicated in patients with: 1) known hypersensitivity or allergy to Tolinase; 2) diabetic ketoacidosis, with or without coma. This condition should be treated with insulin; 3) Type I diabetes, as sole therapy. The administration of oral hypoglycemic drugs has been reported to be associated with increased cardiovascular mortality as compared to treatment with diet alone or diet plus insulin. This warning is based on the study conducted by the University Group Diabetes Program (UGDP), a long-term prospective clinical trial designed to evaluate the effectiveness of glucose-lowering drugs in preventing or delaying vascular complications in patients with noninsulin-dependent diabetes. The study involved 823 patients who were randomly assigned to one of four treatment groups (DIABETES, 19 (supp. A significant increase in total mortality was not observed, but the use of tolbutamide was discontinued based on the increase in cardiovascular mortality, thus limiting the opportunity for the study to show an increase in overall mortality. Despite controversy regarding the interpretation of these results, the findings of the UGDP study provide an adequate basis for this warning. The patient should be informed of the potential risks and advantages of Tolinase and of alternative modes of therapy. All sulfonylurea drugs are capable of producing severe hypoglycemia. Proper patient selection and dosage and instructions are important to avoid hypoglycemic episodes. Renal or hepatic insufficiency may cause elevated blood levels of tolazamide and the latter may also diminish gluconeogenic capacity, both of which increase the risk of serious hypoglycemic reactions. Elderly, debilitated, or malnourished patients and those with adrenal or pituitary insufficiency are particularly susceptible to the hypoglycemic action of glucose lowering drugs. Hypoglycemia may be difficult to recognize in the elderly and in people who are taking beta-adrenergic blocking drugs. Hypoglycemia is more likely to occur when caloric intake is deficient, after severe or prolonged exercise, when alcohol is ingested, or when more than one glucose-lowering drug is used. When a patient stabilized on any diabetic regimen is exposed to stress such as fever, trauma, infection, or surgery, loss of control of blood glucose may occur. At such times it may be necessary to discontinue Tolinase Tablets and administer insulin. The effectiveness of any hypoglycemic drug, including Tolinase, in lowering blood glucose to a desired level decreases in many patients over a period of time, which may be due to progression of the severity of the diabetes or to diminished responsiveness to the drug. This phenomenon is known as secondary failure to distinguish it from primary failure in which the drug is ineffective in an individual patient when first given. Adequate adjustment of dose and adherence to diet should be assessed before classifying a patient as a secondary failure. Patients should be informed of the potential risks and advantages of Tolinase and of alternative modes of therapy. They should also be informed about the importance of adherence to dietary instructions, of a regular exercise program, and of regular testing of urine and/or blood glucose. Blood and urine glucose should be monitored periodically. Measurement of glycosylated hemoglobin may be useful in some patients. The hypoglycemic action of sulfonylureas may be potentiated by certain drugs including nonsteroidal anti-inflammatory agents and other drugs that are highly protein bound, salicylates, sulfonamides, chloramphenicol, probenecid, coumarins, monoamine oxidase inhibitors, and beta-adrenergic blocking agents. When such drugs are administered to a patient receiving Tolinase, the patient should be closely observed for hypoglycemia. When such drugs are withdrawn from a patient receiving Tolinase, the patient should be observed closely for loss of control. Certain drugs tend to produce hyperglycemia and may lead to loss of control. These drugs include the thiazides and other diuretics, corticosteroids, phenothiazines, thyroid products, estrogens, oral contraceptives, phenytoin, nicotinic acid, sympathomimetics, calcium channel blocking drugs, and isoniazid. When such drugs are administered to a patient receiving Tolinase, the patient should be closely observed for loss of control. When such drugs are withdrawn from a patient receiving Tolinase, the patient should be observed closely for hypoglycemia. In a bioassay for carcinogenicity, rats and mice of both sexes were treated with tolazamide for 103 weeks at low and high doses. Tolinase, administered to pregnant rats at ten times the human dose, decreased litter size but did not produce teratogenic effects in the offspring. In rats treated at a daily dose of 14 mg/kg no reproductive aberrations or drug related fetal anomalies were noted. At an elevated dose of 100 mg/kg per day there was a reduction in the number of pups born and an increased perinatal mortality. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, Tolinase is not recommended for the treatment of the pregnant diabetic patient. Serious consideration should also be given to the possible hazards of the use of Tolinase in women of child bearing age and in those who might become pregnant while using the drug. Prolonged severe hypoglycemia (four to ten days) has been reported in neonates born to mothers who were receiving a sulfonylurea drug at the time of delivery. This has been reported more frequently with the use of agents with prolonged half-lives. If Tolinase is used during pregnancy, it should be discontinued at least two weeks before the expected delivery date. Although it is not known whether tolazamide is excreted in human milk, some sulfonylurea drugs are known to be excreted in human milk. Because the potential for hypoglycemia in nursing infants may exist, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother. If the drug is discontinued and if diet alone is inadequate for controlling blood glucose, insulin therapy should be considered. Elderly patients are particularly susceptible to the hypoglycemic action of glucose lowering drugs. Hypoglycemia may be difficult to recognize in the elderly (see PRECAUTIONS ). The initial and maintenance dosing should be conservative to avoid hypoglycemic reactions (see DOSAGE AND ADMINISTRATION ). Elderly patients are prone to develop renal insufficiency,which may put them at risk of hypoglycemia. Dose selection should include assessment of renal function. Tolinase Tablets have generally been well tolerated. In clinical studies in which more than 1,784 diabetic patients were specifically evaluated for incidence of side effects, only 2. Cholestatic jaundice may occur rarely; Tolinase Tablets should be discontinued if this occurs. Gastrointestinal disturbances, eg, nausea, epigastric fullness, and heartburn, are the most common reactions and occurred in 1% of patients treated during clinical trials. They tend to be dose-related and may disappear when dosage is reduced. Allergic skin reactions, eg, pruritus, erythema, urticaria, and morbilliform or maculopapular eruptions, occurred in 0. These may be transient and may disappear despite continued use of Tolinase; if skin reactions persist, the drug should be discontinued.

Hospital treatment may be necessary in some cases for a comprehensive assessment and stabilization purchase januvia toronto. The Empowerment Model (Turkus cheap 100mg januvia overnight delivery, Cohen buy generic januvia 100 mg on line, Courtois discount januvia 100 mg, 1991) for the treatment of survivors of childhood abuse--which can be adapted to outpatient treatment--uses ego-enhancing, progressive treatment to encourage the highest level of function ("how to keep your life together while doing the work"). The use of sequenced treatment using the above modalities for safe expression and processing of painful material within the structure of a therapeutic community of connectedness with healthy boundaries is particularly effective. Group experiences are critical to all survivors if they are to overcome the secrecy, shame, and isolation of survivorship. Stabilization may include contracts to ensure physical and emotional safety and discussion before any disclosure or confrontation related to the abuse, and to prevent any precipitous stop in therapy. Physician consultants should be selected for medical needs or psychopharmacologic treatment. Antidepressant and antianxiety medications can be helpful adjunctive treatment for survivors, but they should be viewed as adjunctive to the psychotherapy, not as an alternative to it. Developing a cognitive framework is also an essential part of stabilization. This involves sorting out how an abused child thinks and feels, undoing damaging self-concepts, and learning about what is "normal". Stabilization is a time to learn how to ask for help and build support networks. The stabilization stage may take a year or longer--as much time as is necessary for the patient to move safely into the next phase of treatment. Diagnosis is in itself a crisis, and much work must be done to reframe DID as a creative survival tool (which it is) rather than a disease or stigma. The treatment frame for DID includes developing acceptance and respect for each alter as a part of the internal system. Each alter must be treated equally, whether it presents as a delightful child or an angry persecutor. Mapping of the dissociative personality system is the next step, followed by the work of internal dialogue and cooperation between alters. This is the critical stage in DID therapy, one that must be in place before trauma work begins. Communication and cooperation among the alters facilitates the gathering of ego strength that stabilizes the internal system, hence the whole person. Revisiting and reworking the trauma is the next stage. This may involve abreactions, which can release pain and allow dissociated trauma back into the normal memory track. An abreaction might be described as the vivid re-experiencing of a traumatic event accompanied by the release of related emotion and the recovery of repressed or dissociated aspects of that event (Steele Colrain, 1990). The retrieval of traumatic memories should be staged with planned abreactions. Hypnosis, when facilitated by a trained professional, is extremely useful in abreactive work to safely contain the abreaction and release the painful emotions more quickly. Some survivors may only be able to do abreactive work on an inpatient basis in a safe and supportive environment. In any setting, the work must be paced and contained to prevent retraumatization and to give the client a feeling of mastery. This means that the speed of the work must be carefully monitored, and the release painful material must be thoughtfully managed and controlled, so as not to be overwhelming. An abreaction of a person diagnosed with DID may involve a number of different alters, who must all participate in the work. The reworking of the trauma involves sharing the abuse story, undoing unnecessary shame and guilt, doing some anger work, and grieving. Throughout this mid-level work, there is integration of memories and, in DID, alternate personalities; the substitution of adult methods of coping for dissociation; and the learning of new life skills. This leads into the final phase of the therapy work. There is continued processing of traumatic memories and cognitive distortions, and further letting go of shame. At the end of the grieving process, creative energy is released. The survivor can reclaim self-worth and personal power and rebuild life after so much focus on healing. There are often important life choices to be made about vocation and relationships at this time, as well as solidifying gains from treatment. This is challenging and satisfying work for both survivors and therapists. Coming through this intense, self-reflective process might lead one to discover a desire to contribute to society in a variety of vital ways. Diagnostic and statistical manual of mental disorders (4th ed. An office mental status examination for complex chronic dissociative symptoms and multiple personality disorder. Psychiatric Clinics of North America, 14(3), 567-604. Facilitating the identification of multiple personality disorder through art: The Diagnostic Drawing Series. Diagnosis and treatment of multiple personality disorder. Multiple personality disorder: Diagnosis, clinical features, and treatment. Abreactive work with sexual abuse survivors: Concepts and techniques. The structured clinical interview for DSM III-R dissociative disorders: Preliminary report on a new diagnostic instrument. Psychotherapy and case management for multiple personality disorder: Synthesis for continuity of care. Psychiatric Clinics of North America, 14(3), 649-660. The empowerment model for the treatment of post-abuse and dissociative disorders. Skokie, IL: International Society for the Study of Multiple Personality Disorder. She is the medical director of The Center: Post-Traumatic Dissociative Disorders Program at The Psychiatric Institute of Washington. A general and forensic psychiatrist in private practice, Dr. Turkus frequently provides supervision, consultation, and teaching for therapists on a national basis. She is co-editor of the forthcoming book, Multiple Personality Disorder: Continuum of Care. Dissociative Disorder CommunityFrom the Archives of Dissociative Living... Multiple Personality Disorder Part 3We have 2514 guests and 3 members onlineHTTP/1. Since then, Debbie has devoted her life to keeping children safe. She is the Founder and President of the child protection group, Safeguarding Our Children - United Mothers (SOC-UM). Our topic tonight is "Protecting Your Children From Sexual Predators". Our guest, Debbie Mahoney, is author and founder of the child protection group Safeguarding Our Children-United Mothers (SOC-UM), which is a site inside the Abuse Issues Community. How old was your son when he was abused by your former neighbor? Like most children, Brian did not disclose the abuse. They did a search on his house and found a project that Brian and I had worked on.

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Bacterial and in vivo mutagenicity tests were uniformly negative buy januvia 100 mg fast delivery. Studies in rats of both sexes at doses up to 75 times the human dose showed no effects on fertility purchase januvia 100mg fast delivery. Long-term carcinogenicity studies were performed with metformin alone in rats (dosing duration of 104 weeks) and mice (dosing duration of 91 weeks) at doses up to and including 900 mg/kg/day and 1500 mg/kg/day januvia 100 mg lowest price, respectively buy januvia with amex. These doses are both approximately 4 times the maximum recommended human daily (MRHD) dose of 2000 mg of the metformin component of Metaglip based on body surface area comparisons. No evidence of carcinogenicity with metformin alone was found in either male or female mice. Similarly, there was no tumorigenic potential observed with metformin alone in male rats. There was, however, an increased incidence of benign stromal uterine polyps in female rats treated with 900 mg/kg/day of metformin alone. There was no evidence of a mutagenic potential of metformin alone in the following in vitro tests: Ames test (S. Results in the in vivo mouse micronucleus test were also negative. Fertility of male or female rats was unaffected by metformin alone when administered at doses as high as 600 mg/kg/day, which is approximately 3 times the MRHD dose of the metformin component of Metaglip based on body surface area comparisons. Teratogenic Effects: Pregnancy Category CRecent information strongly suggests that abnormal blood glucose levels during pregnancy are associated with a higher incidence of congenital abnormalities. Most experts recommend that insulin be used during pregnancy to maintain blood glucose as close to normal as possible. Because animal reproduction studies are not always predictive of human response, Metaglip should not be used during pregnancy unless clearly needed. No animal studies have been conducted with the combined products in Metaglip. The following data are based on findings in studies performed with the individual products. Glipizide was found to be mildly fetotoxic in rat reproductive studies at all dose levels (5-50 mg/kg). This fetotoxicity has been similarly noted with other sulfonylureas, such as tolbutamide and tolazamide. The effect is perinatal and believed to be directly related to the pharmacologic (hypoglycemic) action of glipizide. In studies in rats and rabbits, no teratogenic effects were found. Metformin alone was not teratogenic in rats or rabbits at doses up to 600 mg/kg/day. This represents an exposure of about 2 and 6 times the MRHD dose of 2000 mg of the metformin component of Metaglip based on body surface area comparisons for rats and rabbits, respectively. Determination of fetal concentrations demonstrated a partial placental barrier to metformin. Nonteratogenic EffectsProlonged severe hypoglycemia (4-10 days) has been reported in neonates born to mothers who were receiving a sulfonylurea drug at the time of delivery. This has been reported more frequently with the use of agents with prolonged half-lives. It is not recommended that Metaglip be used during pregnancy. However, if it is used, Metaglip should be discontinued at least 1 month before the expected delivery date. Studies in lactating rats show that metformin is excreted into milk and reaches levels comparable to those in plasma. Similar studies have not been conducted in nursing mothers. Because the potential for hypoglycemia in nursing infants may exist, a decision should be made whether to discontinue nursing or to discontinue Metaglip, taking into account the importance of the drug to the mother. If Metaglip is discontinued, and if diet alone is inadequate for controlling blood glucose, insulin therapy should be considered. Safety and effectiveness of Metaglip in pediatric patients have not been established. Of the 87 patients who received Metaglip in the second-line therapy trial, 17 (19. No overall differences in effectiveness or safety were observed between these patients and younger patients in either the initial therapy trial or the second-line therapy trial, and other reported clinical experience has not identified differences in response between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out. Metformin hydrochloride is known to be substantially excreted by the kidney and because the risk of serious adverse reactions to the drug is greater in patients with impaired renal function, Metaglip should only be used in patients with normal renal function (see CONTRAINDICATIONS, WARNINGS, and CLINICAL PHARMACOLOGY: Pharmacokinetics). Because aging is associated with reduced renal function, Metaglip should be used with caution as age increases. Care should be taken in dose selection and should be based on careful and regular monitoring of renal function. Generally, elderly patients should not be titrated to the maximum dose of Metaglip (see also WARNINGS and DOSAGE AND ADMINISTRATION ). In a double-blind 24-week clinical trial involving Metaglip as initial therapy, a total of 172 patients received Metaglip 2. The most common clinical adverse events in these treatment groups are listed in Table 4. Table 4: Clinical Adverse Events >5% in any Treatment Group, by Primary Term, in Initial Therapy StudyUpper respiratory infectionIn a double-blind 18-week clinical trial involving Metaglip as second-line therapy, a total of 87 patients received Metaglip, 84 received glipizide, and 75 received metformin. The most common clinical adverse events in this clinical trial are listed in Table 5. Table 5: Clinical Adverse Events >5% in any Treatment Group, by Primary Term, in Second-Line Therapy StudyThe dose of glipizide was fixed at 30 mg daily; doses of metformin and Metaglip were titrated. In a controlled initial therapy trial of Metaglip 2. In a controlled second-line therapy trial of Metaglip 5 mg/500 mg, the numbers of patients with hypoglycemia documented by symptoms and a fingerstick blood glucose measurement ?-T50 mg/dL were 0 (0%) for glipizide, 1 (1. Gastrointestinal symptoms of diarrhea, nausea/vomiting, and abdominal pain were comparable among Metaglip, glipizide and metformin in the second-line therapy trial. Overdosage of sulfonylureas, including glipizide, can produce hypoglycemia. Mild hypoglycemic symptoms, without loss of consciousness or neurological findings, should be treated aggressively with oral glucose and adjustments in drug dosage and/or meal patterns. Close monitoring should continue until the physician is assured that the patient is out of danger. Severe hypoglycemic reactions with coma, seizure, or other neurological impairment occur infrequently, but constitute medical emergencies requiring immediate hospitalization. If hypoglycemic coma is diagnosed or suspected, the patient should be given a rapid intravenous injection of concentrated (50%) glucose solution. This should be followed by a continuous infusion of a more dilute (10%) glucose solution at a rate that will maintain the blood glucose at a level above 100 mg/dL. Patients should be closely monitored for a minimum of 24 to 48 hours, since hypoglycemia may recur after apparent clinical recovery. Clearance of glipizide from plasma would be prolonged in persons with liver disease. Because of the extensive protein binding of glipizide, dialysis is unlikely to be of benefit. Overdose of metformin hydrochloride has occurred, including ingestion of amounts >50 g. Hypoglycemia was reported in approximately 10% of cases, but no causal association with metformin hydrochloride has been established. Lactic acidosis has been reported in approximately 32% of metformin overdose cases (see WARNINGS ). Metformin is dialyzable with a clearance of up to 170 mL/min under good hemodynamic conditions.