Revision of the ILO Guidelines for medical examinations of seafarers Part I

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Revision of the ILO Guidelines for medical examinations of seafarers Part I[edit | edit source]

The revision is done on request to MAHRE-Net in Feb 2021 from the International Maritime Health Association (IMHA)https://www.imha.net/, http://europeche.chil.me/ Europeche and European Transport Workers https://www.etf-europe.org/

Authors: The International Diabetes Mellitus and Hypertension Research Group
A subgroup of MAHRE-Net

Seafarers[edit | edit source]

Studies over the decennia show an over-frequency of cancer, cardiovascular disease diabetes and occupational accidents in seafaring compared to other occupations, now decreasing to about the same level as for shore based occupations [1][2]; [3]. The specific physical, chemical and psychological working environment factors on board also relate to the seafarers health conditions. [4] [5]; [6]. Work on tankers carrying gasoline with more or less closed handling of the cargo may still lead to significant benzene exposure for deck crew members .Work-related diseases are primarily the result of physical work environment impacts in the form of noise and vibration, but also hearing damage and seasickness are well known[7] Finally, infectious diseases, including tropical diseases, are a particular problem in certain geographical areas, where also strong exposure to ultraviolet radiation from the sun can cause sunburn and skin cancer. The quality of the mental work environment is dependent on a number of factors which have been carefully described in the past approx. 30 years [8], [9] , [10] Ships with on-going replacement of crew present great challenges for the managers, the employees and the culture at the workplace [11], [12] During navigation, the sailors are often moved to very small working groups, where conflict management can be difficult. The requirements are very variable, the nature of the work requires considerable discipline and thus less self-control. Support from superiors and colleagues can be made difficult by the fact that crews come from many different nationalities. These conditions can lead to experienced stress and burnout [13] [14]. Fatigue is considered a significant health and safety problem [15]. Jet lag after long flights for joining is described as part of this.(12) [16].In the latest research Helen Sampson, director of Cardiff University's Seafarers International Research Centre, said that seafarers working on cargo ships "experience very little happiness on board". She said there was evidence recent-onset psychological disorders were increasing among serving seafarers but 55% of employers said they had not introduced any policies or practices to address mental health for a decade. The report, Seafarers' mental health and wellbeing, found that internet access would make the most significant contribution to improving the mental health and wellbeing together with other key recommendations were underscored in the report and the BBC News [17], [18] Part I: Part II (link)

Guidance to persons authorized by competent authorities to conduct medical examinations and to issue medical certificates p 21ff->[edit | edit source]

Citations from the “Guidelines”: in Italics Health-promotion data supplemental to the ‘fit-for-duty’ data This revision covers the Seafarers and the Fishers Guidelines for medical examinations [19][20]. The revision is based on the evidence for the low validity of the urine-stick test for the early diagnosis of type 2 diabetes [21][22]. The guidelines for seafarers’ medical examinations include health promotion beyond the fit-for-duty protocol, page: p.18 (iv), which is the core issue here: “The medical examination can be used to provide an opportunity to identify early disease or risk factors for subsequent illness. The seafarer can be advised on preventive measures or referred for further investigation or treatment in order to maximize their opportunities for continuing their career at sea” Our focus is on the early diagnosis and early implementation of T2DM health prevention to preserve good health in general and good eyesight, specifically, for the seafarers who are dependent on good vision to remain in their jobs for many years. The proposed health-promotion program focusing on T2DM and hypertension has an impact on all types of metabolic syndrome diseases and can help keep workers active for more years. The aim is to provide a foundation for the evidence base to foster safe and healthy preventive strategies and policies within the UN Global Sustainable Goals, especially Goal 3: Good health and well-being for all workers and Goal 8: Decent Work and Economic Growth[23]. Effective health promotion, however, is dependent on research, which, in turn, depends on access to valid data. The centralization of data is needed for the research for health promotion regarding T2DM, hypertension and related metabolic syndrome diseases. In conclusion, Appendix F should be completed as before but supplemented by the Appendix F-1 Scientific Data Form for research purposes.

XII. Conducting medical examinations, pg18[edit | edit source]

Unfortunately, the model for how to report laboratory data, especially in regard to urine-stick tests in Appendix F in the “Guidelines” has been misunderstood by maritime authorities as well as maritime doctors for many years. In the fit-for-duty guidelines, the national authorities have chosen to follow the example on page 51 (Appendix F) in the ‘Guidelines’ by asking for the results (glucose, protein, blood) based on urine dipstick analysis without mentioning the need for a supplemental HbA1C or similar high-validity test for the unbiased early diagnosis of T2D(1). Although urine dipsticks can be used to determine pathological changes in urine, they cannot serve as a valid diagnostic tool for T2D. Indeed, a review of studies on using urine dipsticks to test for T2D concluded that they should not be used due to their low sensitivity to detect T2D accurately, with the consequence of a high number of false negative tests. In one such study, the sensitivity of the urine dipstick to detect T2D correctly was 20.8% (95% CI: 8.1–52.8%), and a similar study from Sweden revealed a sensitivity of 18.1% versus the far higher sensitivities of fasting glucose and HbA1C.[24][25]. Neglecting to use valid tests for the early diagnosis of T2D internationally in the fit-for-duty tests over decennia may have increased the prevalence of major microvascular complications and quality-adjusted life-years (QALYs) as well as financial losses for workers, employers and states.

Text to be corrected pg.20 (x)

“The validity of any test used for the identification of a relevant medical condition will depend on the frequency with which the condition occurs. Use is a matter for national or local judgement, based on disease incidence and test validity. The meaning of this text is unclear, and should be replaced by the following: “Sensitivity and specificity describe the accuracy of a test that reports the presence or absence of a condition. In a diagnostic test, sensitivity is a measure of how well a test can identify true positives”

Attention to the seafarers´ specific working conditions[edit | edit source]

The medical specialist in maritime medicine should pay particular attention to the fact that seafarers are vulnerable patients compared to most shore workers and may need to be referred to specialists in suspected cases of (pre-)hypertension and or (pre-)T2DM to be noted in the scientific data sheet (APPENDIX F-1) While the ‘Guidelines’ should be openly promoted, the data collection for research should be included as part of the medical health examinations, and the medical health examinations report should be divided into two parts:

Diabetes and hypertension prevention programs[edit | edit source]

Simple lifestyle measures have been shown to be effective in preventing or delaying the onset of type 2 diabetes, hypertension and its complications:

  1. Achieve and maintain healthy body weight
  2. Physically active – doing at least 30 minutes of regular, moderate-intensity activity on most days. More activity is required for weight control
  3. Eat a healthy diet, avoiding sugar and saturated fats
  4. Avoid tobacco use – smoking increases the risk of diabetes and cardiovascular disease

Intervention in collaboration with the shareholders[edit | edit source]

The success of the personal struggles depends however, on supportive environments, established by the shareholders with the needed conditions for good health practices for persons with diabetes, hypertension and all others with risk for chronic metabolic diseases. The shareholders are prompted to establish the specific conditions at work that are needed for seafarers to maintain good health practices, especially for employees with type 2 diabetes and hypertension in different types of jobs. The shareholders are challenged to maintain a stable and supportive health environment for fishers and seafarers who work up to 12 hours per day over several months away from shore. A supportive environment includes opportunities during workdays for time and allowance for relevant work breaks, restroom visits, access to nutritious meals in good social company, time off and possibilities for adequate physical activity. The necessary conditions are different in various job groups, and an analysis of these conditions and suggestions for how they can be made optimal is needed. Implementations for adequate structural changes in workplaces, sufficient time for meal breaks and restroom visits, cooks who prepare healthful lunches, a fitness room and other relevant installations should be considered imperative. Among the important shareholders are also the authorities to give permission to run specific research projects with access to the needed data as example about the risk on Diabetes type-2 if the good advises are not followed.

How to make accurate Blood pressure measurements in the clinic?[edit | edit source]

For the accurate diagnosis and management of Blood pressure, proper methods are recommended for the accurate measurement and documentation of BP [26].

A recognized automatic blood pressure measurement apparatus should be used. Three measurements should be carried out by the examining physician. Measurements should be carried out on the subject in a seated position.

HTN is the most attributable modifiable cardiovascular disease (CVD) events risk factor. In recent years the incidence and prevalence of HTN have increased while rates of HTN control have declined.[27] Measuring blood pressure is one of the most common procedures performed at a medical office. Yet, studies have shown that nurses, medical assistants and even doctors make numerous mistakes when taking readings. Accurate measurement of blood pressure is essential to classify individuals, to ascertain blood pressure–related risk, and to guide management. The auscultatory technique with a trained observer and mercury sphygmomanometer continues to be the method of choice for measurement in the office, using the first and fifth phases of the Korotkoff sounds. The use of mercury is declining, and alternatives are needed. Aneroid devices are suitable, but they require frequent calibration. Hybrid devices that use electronic transducers instead of mercury have promise.[28]

Guidelines on diagnosing HTN recommend certain aspects that we must take into account and certain things that we must avoid:

  • In the 30 minutes before your blood pressure is taken, no smoking, no caffeine and no exercise. In the 5 minutes before your blood pressure is taken sit still.
  • During blood pressure is taken make sure the cuff is the right size and in the right place, keep your cuffed arm on a flat surface, like a table and at heart level, sit upright, feet flat on floor and don`t talk.[29]

Avoid this things:[30]

  • Putting the cuff over clothing, rather than a bare arm, can add 10-40 mm Hg to a measurement.
  • Having a full bladder can tack on 10-15 mm Hg.
  • Talking or having a conversation: an additional 10-15 mm Hg.
  • Failing to support the arm at heart level can add 10 mm Hg.
  • An unsupported back can increase a measurement by 5-10 mm Hg. That same range applies to feet left dangling from an exam table or high chair.
  • Crossing legs means an extra 2-8 mm Hg

Self-hypertensive control on board and at home[edit | edit source]

Self-monitoring of patients hypertension is necessary. Instructions and the relevant equipment in the Ships medical Chest on board is required). In addition, courses are needed as well as revisions to the International Medical Guide for Ships (and ships’ medical Chest)[31] During sailing it shall be possible to measure blood pressure in individuals having treatment for high blood pressure. At least two automatic apparatus should be available on all ships in case one of the devices breaks Ships Medical Chest[32][33]

Measure Your Blood Pressure on a Regular Basis[edit | edit source]

Measuring your blood pressure is an important step toward keeping a healthy blood pressure. Because high blood pressure and elevated blood pressure often have no symptoms, checking your blood pressure is the only way to know for sure whether it is too high. You can measure your blood pressure at home and at sea with a home blood pressure monitor Learn steps you can take to lower your risk for health problems from high blood pressure such as heart disease and stroke. Request equipments should be in the Ships Medical Chest[32][33]

When should hypertensive seafarers be referred to hypertension clinics?[edit | edit source]

Compared to shore workers, seafarers are socially vulnerable hypertension patients with a need for special attention and may need to be referred to a hypertension clinic[34][35]. A referral can also be relevant for providing instructions for self-hypertensive control on board and at home. The findings from randomised controlled trial, followed up for 6- and 12-months in primary care settings in Hong Kong. Patients newly diagnosed with grade 1 hypertension (aged 40-70 years) were consecutively recruited. Automatic referral of newly diagnosed grade 1 hypertensive patients for further one-to-one dietitian counseling on top of primary care physician's usual care. The findings did not support automatic referral of newly diagnosed grade 1 hypertensive patients. Patients with those risk factors identified should receive more clinical attention to reduce their CV risk [36](possibly add more studies)

How to make accurate diagnosis of T2DM in the clinic (and the diagnostic costs)[edit | edit source]

Urinary glucose has been widely used as a screening tool for diabetes being non-invasive and easy to perform. The renal threshold for glucose (approximately 10 mmol/l) corresponds well to a relevant screening level for postprandial hyperglycemia[37]. However, the method is unable to pick up elevated fasting- and preprandial hyperglycemia below this threshold, and while it reflects an average level of blood glucose since last voiding, it cannot reflect chronic hyperglycemia. Furthermore, under- or overestimation is seen in conditions with high- (long diabetes duration or kidney failure) or low- (pregnancy, children, MODY diabetes) renal glucose thresholds[38][39]. Finally, fluid intake may influence urine concentration and thus glycosuria test results.

Since 2011, Glycolated Hemoglobin (HbA1c) has been used to diagnose diabetes in most countries and replaced blood glucose performed in the fasting state or 2 hours after and oral glucose tolerance test[40]. A confirmed HbA1c concentration ≥ 48 mmol/mol defines diabetes. The use of HbA1c was made possible after establishment of a reference measurement procedure for international standardization of routine HbA1c assays[41]. There were several reasons for this recommendation. HbA1c was already used in clinical practice for decision making on antidiabetic treatment. Compared to glucose measures, HbA1c is stronger associated with most long-term micro- and macrovascular diabetes complications[42]. Measurement variability is negligible (~1%) compared to blood glucose (12-15%)[43]. HbA1c does not require fasting and is obviously less time consuming than the cumbersome oral glucose tolerance test. In some cases, a blood glucose measure may be a relevant alternative to the HbA1c, primarily in conditions where HbA1c does not fully reflect glucose levels, such as severe anemia, kidney failure, or in persons with hemoglobinopathies[44]. Importantly, for low income countries, HbA1c is a rather expensive measure, and not possible to apply to the general diabetes population [45].

When should a T2DM seafarer be referred to a specialist department[edit | edit source]

Transport workers like seafarers and truck, bus, train, and taxi drivers as well as fishers are known to have significant inequities regarding their health at work, including a high risk of developing type 2 diabetes. Compared to shore workers, seafarers are socially vulnerable type 2 diabetes patients with a need for special attention, as described by Rogvi et al[46].If a diabetes patient has any kind of diabetic complication he or she should be referred to a specialized diabetes clinic if possible (FG)

Self-management of diabetes and hypertension on board and at home[edit | edit source]

Self-monitoring of blood glucose for non-insulin-treated adults with Type 2 diabetes is necessary. Instructions and relevant equipment in the medical chest on board are needed and have been added to the actual revision of the International Medical Guide for Ships and the Medical Inventory lists. A few crew embers on board shall know how to measure blood glucose and to treat severe hypoglycemia  using glucagon, which must be present on all ship chests.FG

Request that equipment for self-control of diabetes type 2 should be in the Ships Medical Chest[32][33].The Norwegian Gard association is one of the advisors for healthy diet and exercises while on board.

  1. The PEME allows for early recognition of seafarers at risk followed by careful monitoring and treatment. Treatment is aimed at correcting lifestyle issues:
  2. Changes in diet to reduce the intake of high sugar foods and beverages and other carbohydrates and increase servings of fruit and vegetables.
  3. Guidelines for Healthy Food Onboard Merchant Ships provides tips for healthy food plans.
  4. Exercising at least three times a week for 30 minutes each time, aiming to achieve an exercise heart rate of 75% of maximum. This can be easily calculated as follows: (220 – age) x 0.75 = recommended heart rate during exercise to derive cardiovascular benefit. For an average 45-year-old, this would mean an exercise heart rate of 131 beats per minute.
  5. Monitoring the blood sugar levels with tests such as urine glucose tests, blood sugar tests and a diabetes control measuring test, an HBA1C, which provides a measure of diabetes control over the last six weeks.
  6. The seafarer must also keep a logbook of their diabetes control to enable them to understand their health condition, and to take responsibility for its management.
  7. Using prescribed medication regularly and notifying their doctor of any change in their diabetes control, so that appropriate adjustments to their treatment regime can be made.

The International Diabetes Federation recommended dietary guidelines for the general population (hypertension)[edit | edit source]

  1. Choosing water, coffee or tea instead of fruit juice, soda, or other sugar sweetened beverages
  2. Eating at least three servings of vegetable every day, including leafy green vegetables
  3. Eating up to three servings of fresh fruit every day
  4. Choosing nuts, a piece of fresh fruit, or unsweetened yoghurt for a snack
  5. Limiting alcohol intake to a maximum of two standard drinks per day
  6. Choosing lean cuts of white meat, poultry or seafood instead of red or processed meat
  7. Choosing peanut butter instead of chocolate spread or jam
  8. Choosing wholegrain bread, rice, or pasta instead of white bread, rice, or pasta
  9. Choosing unsaturated fats (olive oil, canola oil, corn oil, or sunflower oil) instead of saturated fats (butter, ghee, animal fat, coconut oil or palm oil).

APPENDIX F[edit | edit source]

The maritime doctors complete the ‘fit-for-duty’ examinations according to the guidelines and send their reports with the information in the APPENDIX F to the maritime authorities.

APPENDIX F-1 Clinical Scientific Data Form[edit | edit source]

The national maritime authorities are urged to include APPENDIX F-1 supplemental to APPENDIX F and make arrangements to transfer the digital data collected in Excel format to the competent national research institute for further analysis, reporting and publication. The reported data in APPENDIX F-1 should be without personal name, ID number or company identification, considered as “non-personal” under the General Data Protection Regulation (GDPR) without need to be acknowledged by the European Ethical Committees Analysis of the epidemiological Prevalence data will allow for the identification of trends and comparisons between the countries etc. To estimate the real prevalence and prevalence rates we include all, regardless of their risk, such as obesity and their age. In Appendix F-1 is underscored that the authorities must give access to the needed data as example to learn from intervention studies in risk on Diabetes type-2[47].

Excel data registration scheme

Inform

Cons

(1)

Age Gend Natio

(2)

Fisher Seaf Waist

cm

Diastolic

Blood Pressure

Systolic

Blood Pressure

A1C

(3)

FSG Hight


cm

Weight

Kg

Do you have Diabetes? y/n

(4)

Do you have Hypertension?

(4) y/n

Take any Medi-cine?(4) ref to

DM spec

ref to Hyp spec
y 33 m 1 x 95 80 130 5,5 175 77 n n n n
  1. Ask the seafarer/fisherman if we can use anonymised data for research
  2. Own country= 1, Other = 2
  3. Variable with decimals in Excel in "Standard" use commas"," not in "."
  4. Copy the answer from interview scheme
  5. Metformin = 1 other medicine = 2
DIABETES TYPE 2 HbA1c Limits Fasting Glucose limits
Actual Measurement: ->
Mark the Diagnosis
Normal ≤ 5,6% ≤ 100 mg/dl
Prediabetes 5.7-6.4% 100 -125 mg/dl
Diabetes ≥ 6,5% ≥126 mg/dl
Diabetes (=taking anti-DM)
HYPERTENSION (HTN) Diastolic Systolic
Actual Measurement: ->
Mark the Diagnosis
Normal 80 130
Prehypertension 80-89 130-139
Hypertension Stage 1 90-99 140-159
Hypertension Stage 2 100+ 160+
HTN=anti-hypertensive med.

Inform seafarer whether (s)he is Non-diabetic, Pre-diabetec or Diabetic give advice and refer to specialist, if needed

Inform seafarer whether: non-hypertensive/pre-hypertensive/ hypertensive (see definitions), give advice and refer to hypertensive specialist if needed.

Use standardized reporting for research purposes, send data to designated international researcher contact (MAHRE-Net)

References[edit | edit source]

  1. ↑ Petersen KU, Hansen HL, Kaerlev L, Hansen J. Turning the tide: reducing mortality among Danish merchant seafarers. Occupational and environmental medicine. 2020;
  2. ↑ Poulsen TR, Burr H, Hansen HL, Jepsen JR. Health of Danish seafarers and fishermen 1970-2010: What have register-based studies found? Scand J Public Health. 2014
  3. ↑ Oldenburg M. Risk of cardiovascular diseases in seafarers. Int Marit Health. 2014;65(2):53–7.
  4. ↑ Oldenburg M, Jensen H-J, Latza U, Baur X. Seafaring stressors aboard merchant and passenger ships. Int J Public Health. 2009;54(2):96–105.
  5. ↑ Oldenburg M, Baur X, Schlaich C. Cardiovascular diseases in modern maritime industry. Int Marit Health. 2010;62(3):101–6.
  6. ↑ MacLachlan M, Kavanagh B, Kay A. Maritime health: a review with suggestions for research. Int Marit Health. 2012;63(1):1–6.
  7. ↑ Jezewska M, Leszczyńska I, Jaremin B. Work-related stress at sea self estimation by maritime students and officers. Int Marit Health. 2006;57(1–4):66–75.
  8. ↑ Levi L. Occupational stressors, biological stress reactions, and worker’s health. J UOEH. 1989 Mar 20;11 Suppl:480–1.
  9. ↑ Leka S. Psychosocial hazards and seafarer health: priorities for research and practice
  10. ↑ Int Marit Health. 2004;55(1–4):137–53.
  11. ↑ Oldenburg M, Jensen H-J, Latza U, Baur X. Seafaring stressors aboard merchant and passenger ships. Int J Public Health. 2009;54(2):96–105.
  12. ↑ Lodde B, Jegaden D, Lucas D, Feraud M, Eusen Y, Dewitte J-D. Stress in seamen and non seamen employed by the same company. Int Marit Health. 2008;59(1–4):53–60.
  13. ↑ Elo AL. Health and stress of seafarers. Scand J Work Environ Health. 1985 Dec;11(6):427–32.
  14. ↑ Oldenburg M, Jensen H-J, Latza U, Baur X. Seafaring stressors aboard merchant and passenger ships. Int J Public Health. 2009;54(2):96–105.
  15. ↑ Allen P, Wadsworth E, Smith A. Seafarers’ fatigue: a review of the recent literature. Int Marit Health. 2008;59(1–4):81–92.
  16. ↑ Wadsworth EJK, Allen PH, McNamara RL, Smith AP. Fatigue and health in a seafaring population. Occup Med. 2008 May 1;58(3):198–204.
  17. ↑ Seafarers mental health and wellbeing SIRC research Nov 2019 https://www.iosh.com/media/6305/seafarers-mental-health-wellbeing-summary-report.pdf
  18. ↑ BBC news on maritime mental health advice based on the research Nov 2019 https://www.bbc.com/news/uk-wales-50315080
  19. ↑ Guidelines on the medical health examinations for seafarers wcms_174794-kopi.pdf
  20. ↑ Guidelines on the medical examinations of fishermen - Buscar con Google [cited 2022 Jan 7]
  21. ↑ Jensen OC, Flores A, Corman V, Canals ML, Lucas D, Denisenko I, et al. Early diagnosis of T2DM using high sensitive tests in the mandatory medical examinations for fishers, seafarers and other transport workers. Prim Care Diabetes [Internet]2022 Jan 4 [cited 2022 Jan 7]; Available from: https://www.sciencedirect.com/science/article/pii/S1751991821002345
  22. ↑ Jensen OC et al. Rethinking the use of urine dipstick for the early diagnosis of Type 2 Diabetes.Submitted Letter to Editor to "Diabetes Research and Clinical Practice"
  23. ↑ THE 17 GOALS | Sustainable Development [Internet]. [cited 2022 Jan 18]. Available from: https://sdgs.un.org/goals
  24. ↑ Wei OY, Teece S. Urine dipsticks in screening for diabetes mellitus. Emerg Med J EMJ. 2006 Feb;23(2):138
  25. ↑ Friderichsen B, Maunsbach M. Glycosuric tests should not be employed in population screenings for NIDDM. J Public Health Med. 1997 Mar;19(1):55–60
  26. ↑ Unger T, Borghi C, Charchar F, Khan NA, Poulter NR, Prabhakaran D, et al. 2020 International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension. 2020 Jun 1;75(6):1334–57
  27. ↑ "New Guidance on Blood Pressure Management in Low-Risk Adults with Stage 1 Hypertension". American College of Cardiology. Retrieved 2022-01-19.
  28. ↑ Pickering, Thomas G.; Hall, John E.; Appel, Lawrence J.; Falkner, Bonita E.; Graves, John; Hill, Martha N.; Jones, Daniel W.; Kurtz, Theodore et al. (2005-02-08). "Recommendations for Blood Pressure Measurement in Humans and Experimental Animals". Circulation 111 (5): 697–716. doi:10.1161/01.CIR.0000154900.76284.F6. https://www.ahajournals.org/doi/full/10.1161/01.cir.0000154900.76284.f6. 
  29. ↑ "How to accurately measure blood pressure at home". www.heart.org. Retrieved 2022-01-19.
  30. ↑ Handler, Joel (2009). "The Importance of Accurate Blood Pressure Measurement". The Permanente Journal 13 (3): 51–54. ISSN 1552-5767. PMID 20740091. PMC 2911816. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2911816/. 
  31. ↑ Shimbo D, Artinian NT, Basile JN, Krakoff LR, Margolis KL, Rakotz MK, et al. Self-Measured Blood Pressure Monitoring at Home: A Joint Policy Statement From the American Heart Association and American Medical Association. Circulation. 2020 Jul 28;142(4):e42–63. https://www.cdc.gov/bloodpressure/manage.htm
  32. ↑ 32.0 32.1 32.2 World Health Organization (2007). International medical guide for ships : including the ship's medicine chest (in en). https://apps.who.int/iris/handle/10665/43814. 
  33. ↑ 33.0 33.1 33.2 "Download inventory lists". dma.dk. Retrieved 2022-01-23.
  34. ↑ Kennedy C, Farnan R, Stinson J, Hall M, Hemeryck L, O’Connor P, et al. Referrals to, and characteristics of patients attending a specialist hypertension clinic. J Hum Hypertens. 2021 Mar 8
  35. ↑ Meador M, Lewis JH, Bay RC, Wall HK, Jackson C. Who Are the Undiagnosed? Disparities in Hypertension Diagnoses in Vulnerable Populations. Fam Community Health. 2020 Jan;43(1):35–45
  36. ↑ Wong, Martin C. S., Harry H. X. Wang, Mandy W. M. Kwan, Shannon T. S. Li, Miaoyin Liang, Franklin D. H. Fung, Ming Sze Yeung, m.fl. “The Effectiveness of Dietary Approaches to Stop Hypertension (DASH) Counselling on Estimated 10-Year Cardiovascular Risk among Patients with Newly Diagnosed Grade 1 Hypertension: A Randomised Clinical Trial”. International Journal of Cardiology 224 (1. December 2016): 79–87. https://doi.org/10.1016/j.ijcard.2016.08.334.
  37. ↑ Goldstein DE, Little RR, Lorenz RA, Malone JI, Nathan D, Peterson CM, Sacks DB. (Meador et al., 2020) Diabetes Care. 2004 Jul;27(7):1761-73. doi: 10.2337/diacare.27.7.1761.
  38. ↑ Alto WA. No need for glycosuria/proteinuria screen in pregnant women. J Fam Pract 2005;54:978
  39. ↑ Menzel R, Kaisaki PJ, Rjasanowski I, Heinke P, Kerner W, Menzel S. A low renal threshold for glucose in diabetic patients with a mutation in the hepatocyte nuclear factor-1alpha (HNF-1alpha) gene. Diabet Med. 1998 Oct;15(10):816-20
  40. ↑ The International Expert Committee. International Expert Committee Report on the Role of the A1C Assay in the Diagnosis of Diabetes. Diabetes Care 2009 Jul; 32(7):1327-1334
  41. ↑ Consensus Committee. Consensus statement on the worldwide standardization of the hemoglobin A1C measurement: American Diabetes Association, European Association for the Study of Diabetes, International Federation of Clinical Chemistry and Laboratory Medicine, and the International Diabetes Federation. Diabetes Care. 2007;30: 2399-2400
  42. ↑ The International Expert Committee. International Expert Committee Report on the Role of the A1C Assay in the Diagnosis of Diabetes. Diabetes Care 2009 Jul; 32(7): 1327-1334
  43. ↑ Ollerton RL, Playle R, Ahmed K, Dunstan FD, Luzio SD, Owens DR. Day-to-day variability of fasting plasma glucose in newly diagnosed type 2 diabetic subjects. Diabetes Care 1999; 22: 394– 398
  44. ↑ Borg R, Persson F, Siersma V, Lind B, de Fine Olivarius N, Andersen CL. Interpretation of HbA1c in primary care and potential influence of anaemia and chronic kidney disease: an analysis from the Copenhagen Primary Care Laboratory (CopLab) Database. Diabet Med. 2018 Jul 9. DOI:10.1111/dme.13776.
  45. ↑ WHO 2011. Use of Glycated Haemoglobin (HbA1c) in the Diagnosis of Diabetes Mellitus. https://www.who.int/diabetes/publications/report-hba1c_2011.pdf
  46. ↑ Rogvi SÁ, Guassora AD, Wind G, Tvistholm N, Jansen SM-B, Hansen IB, et al. Adjusting health care: practicing care for socially vulnerable type 2 diabetes patients. BMC Health Serv Res. 2021 Sep 10;21(1):949
  47. ↑ Tanenbaum ML, Leventhal H, Breland JY, Yu J, Walker EA, Gonzalez JS. Successful self-management among non-insulin-treated adults with Type 2 diabetes: a self-regulation perspective. Diabet Med J Br Diabet Assoc. 2015 Nov;32(11):1504–12
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