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“The intent of the General Assembly … was that you could not do one absent the other,” he said.

Garrett, a Republican, said he long opposed plans to add 400,000 adults to Medicaid because of cost concerns. He said requiring these enrollees to work or do volunteer service would make them healthier and improve their well-being.

Patricia Boozang, senior managing director for Manatt Health, a consulting firm, said she is not surprised states are moving ahead with work requirement plans regardless of the court ruling, which was specific to Kentucky.

She said the decision would cause the Trump administration to review the pending applications more closely so they could withstand a judicial review.

The federal court said Health and Human Services Secretary Alex Azar did not adequately take into account how many people would lose coverage for the work requirement and did not prove such a provision would improve enrollees’ health.

“It’s going to be challenging for them to make the case that health and well-being is going to be improved by the [work requirement] waiver,” she said.

In Arkansas, some Medicaid enrollees face a Thursday deadline to register their status — that they worked, did volunteer service in June or meet one of the state’s many exemptions.

“The ruling does not have an immediate effect on Arkansas’ work requirement,” said spokeswoman Marci Manley.

Advocates for low-income people are weighing whether to file lawsuits to stop the work requirement in other states that have won federal approval.

“We have … partnerships with state legal advocates in these states and are exploring enforcement and litigation options with them,” said Jane Perkins, legal director of the National Health Law Program, which filed the suit on behalf of Medicaid enrollees in Kentucky to block the work requirements.

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The Other Victims: First Responders To Horrific Disasters Often Suffer In Solitude

Insulin glargine may be released from the microprecipitate by proteolytic degradation leading to soluble yet fully metabolically active metabolites. In vivo metabolism studies in rats and dogs have demonstrated significant plasma levels of two main metabolites of insulin glargine, M1 ([Gly A21 ]insulin) and M2 ([Gly A21 ,des-Thr B30 ]insulin), formed by the sequential removal of the two arginines from the carboxy-terminus of the B-chain and additional deamination of the threonine in position B30. The intermediate IM ([Gly A21 ,Arg B31 ]insulin) can be detected as minor species only ( Fig. 1 ) [9] . This pattern of insulin glargine metabolism was also observed following its subcutaneous administration in healthy humans [10] . Interestingly, degradation to both M1 and M2 occurred at the site of injection and continued within the circulatory system, although with considerable variation in efficacy and time course between the individuals tested. Analysis of tissue samples from the site of injection revealed an average ratio of 50∶50 for parent compound and M1/M2 [10] . In vitro incubation of insulin glargine in 69 sera for 30 minutes at 37°C resulted in metabolizing of insulin glargine into M1 from 46% to 98% [11] . The processing enzymes have not been identified so far, but metallocarboxypeptidases such as carboxypeptidases E, H, N and U represent candidates for the rapid and efficient metabolism of insulin glargine [11] . These enzymes are found in plasma and are likely to occur also in subcutaneous tissues [11] .

Figure 1. Insulin glargine metabolites.

The long-acting insulin glargine (Lantus®, [Gly A21 ,Arg B31 ,Arg B32 ]insulin) is metabolized in vivo in subcutaneous tissue and in bloodstream of healthy humans by sequential cleavage of the C-terminus of the B chain. Two primary degradation products M1 and M2 have been reported, which are both structural similar to human insulin [10] . Besides M1 and M2 an intermediate IM was also identified but only in minor quantities.

The efficient generation of IM, M1, and M2 at the subcutaneous injection site and in plasma carries the notion that the proteolytic degradation products of insulin glargine contribute to the long-lasting systemic metabolic activity at least in part. In addition, it may shed new light on the current intense and controversial debate concerning the growth-promoting activity of human insulin and insulin analogs as determined in vitro [12] [15] and its in vivo relevance for insulin therapy [16] [18] . The growth-promoting effects of human insulin or insulin analogs are usually studied in cell lines under in vitro experimental conditions in the absence of IGF's and other physiological serum growth factors. However, several such studies have yielded conflicting results that may be due to experiment-to-experiment variability in specific cell lines and/or to the precise experimental conditions used [18] , [19] .

Both low and high blood sugar can cause problems and need to be treated. Your doctor will suggest how often your child's blood sugar should be checked.

See your child's doctor at least every 3 to 6 months to check how well the treatment is working. During these visits, the doctor will do some tests to see if your child's blood sugar is under control. Based on these results, the doctor may change your child's treatment plan.

When your child is 10 years old or starts puberty, he or she will start having exams and tests to look for any problems from diabetes.

Your child's insulin dose and possibly the types of insulin may change over time. The way your child takes insulin (with shots or an insulin pump ) also may change. This is especially true during the teen years when your child grows and changes a lot.

What and how much food your child needs will also change over the years. But it will always be important to eat about the same amount of carbohydrate at each meal. Carbohydrate is the nutrient that most affects blood sugar.

Health Tools help you make wise health decisions or take action to improve your health.


Type 1 diabetes develops because the body's immune system destroys beta cells in a part of the pancreas called the islet tissue. Beta cells produce insulin. So children with type 1 diabetes can't make their own insulin. Experts do not know what causes this to happen. But the cause may involve family history and maybe environmental factors like diet or infections.

Type 1 diabetes develops when your child's pancreas stops producing enough insulin . Insulin lets blood sugar-also called glucose-enter the body's cells, where it is used for energy. Without insulin, the amount of sugar in the blood rises above a safe level. As a result, your child experiences high and low blood sugar levels from time to time. High blood sugar can damage blood vessels and nerves throughout the body and increases your child's risk of eye, kidney, heart, blood vessel, and nerve diseases.

Causes of high blood sugar

Causes of low blood sugar


Because your child has type 1 diabetes, he or she will experience high and low blood sugar levels from time to time. High blood sugar usually develops slowly over hours or days, so you can treat the symptoms before they become severe and require medical attention. On the other hand, your child's blood sugar level can drop to dangerously low levels in minutes.

Be alert for:

How can you tell the difference?

Sometimes it's hard to distinguish between high and low blood sugar symptoms , especially if your child is very young. Test your child's blood sugar whenever you think it may be high or low so that you can treat it appropriately. If your child has symptoms of very high blood sugar, such as a fruity breath odor, vomiting, and/or belly pain, seek emergency care. These symptoms may point to diabetic ketoacidosis , which is a life-threatening emergency.

What Happens

Every child experiences type 1 diabetes differently.

The negative effects of diabetes are caused by blood sugar levels that are above or below a target range .

Low blood sugar

Very low blood sugar is a frightening experience for you and your child. But if low blood sugar levels are treated quickly and appropriately, your child should have no lasting effects.

Young children cannot recognize low blood sugar symptoms as well as adults can, which puts them at risk for low blood sugar emergencies. Children who develop hypoglycemia unawareness , which is the inability to recognize early symptoms of low blood sugar until they become severe, or who are trying to keep their blood sugar levels tightly within a target range are also at risk for low blood sugar emergencies.

Make sure your child's caregivers, such as school nurses, know:

Let your doctor know if your child is having frequent episodes of low blood sugar. You can use this form (What is a document?) to keep a record of your child's very high or very low blood sugar levels.

High blood sugar

Very high blood sugar puts your child at risk for diabetic ketoacidosis , a life-threatening emergency. Skipping insulin injections, stress, illness, injury, and puberty can trigger high blood sugar. Because blood sugar levels usually rise slowly, you can treat symptoms early and, most often, prevent diabetic ketoacidosis.

High blood sugar can also lead to:

What can be done?

The best way to help your child with type 1 diabetes live a long and healthy life is to keep his or her blood sugar levels within a target range. Work with your child's doctor, and monitor blood sugar levels frequently.

What Increases Your Risk

Risk factors for very high or low blood sugar levels in a child with type 1 diabetes include:

Call 911 or other emergency services right away if your child:

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