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It is critical to discuss with your doctor the number to be transferred before the transfer is done. In an effort to help curtail the problem of multiple pregnancies (see multiple pregnancies), national guidelines published in 2013 recommend limits on the number of embryos to transfer (see Tables below). These limits should not be viewed as a recommendation on the number of embryos to transfer. Recommended limits on the number of embryos to transfer Age < 35 Embryos -favorable -not favorable Blastocysts -favorable -not favorable 1 or 2 2 1 2 Age 35-37 2 3 2 2 Age 38-40 3 4 3 3 Age >40 5 5 3 3 In some cases, there will be additional embryos remaining in the lab after the transfer is completed. Depending on their developmental normalcy, it may be possible to freeze them for later use. Hormonal support of the uterine lining Successful attachment of embryo(s) to the uterine lining depends on adequate hormonal support. Progesterone, given by the intramuscular or vaginal route, is routinely given for this purpose. Successful attachment of embryos to the uterine lining (endometrium) depends on adequate hormonal support of the lining. Therefore, progesterone is routinely given, and in some cases, estradiol is also prescribed. Some men with extremely low or absent sperm counts have small deletions on their Y chromosome. A Y chromosome microdeletion can often, but not always, be detected by a blood test. Assisted Hatching Assisted hatching involves making a hole in the outer shell (zona pellucida) that surrounds the embryo. Hatching may make it easier for embryos to escape from the shell that surrounds them. The cells that make up the early embryo are enclosed within a flexible membrane (shell) called the zona pellucida. During normal development, a portion of this membrane dissolves, allowing the embryonic cells to escape or "hatch" out of the shell. Only upon hatching can the embryonic cells implant within the wall of the uterus to form a pregnancy. Assisted hatching is the laboratory technique in which an embryologist makes an artificial opening in the shell of the embryo. The hatching is usually performed on the day of transfer, prior to loading the embryo into the transfer catheter. The opening can be made by mechanical means (slicing with a needle or burning the shell with a laser) or chemical means by dissolving a small hole in the shell with a dilute acid solution. Risks that may be associated with assisted hatching include damage to the embryo resulting in loss of embryonic cells, or destruction or death of the embryo. Artificial manipulation of the zygote may increase the rates of monozygotic (identical) twinning which are significantly more complicated pregnancies. Cryopreservation Freezing of eggs and embryos can provide additional chances for pregnancy. Frozen eggs and embryos do not always survive the process of freezing and thawing. Ethical and legal dilemmas can arise when couples separate or divorce, especially for embryos; disposition agreements are essential. It is the responsibility of each couple with frozen eggs and / or embryos to remain in contact with the clinic on an annual basis. Since multiple eggs (oocytes) are often produced during ovarian stimulation, on occasion there are more embryos available than are considered appropriate for transfer to the uterus. Both strategies save the expense and inconvenience of stimulation to obtain additional eggs in the future. Furthermore, the availability of cryopreservation permits patients to transfer fewer embryos during a fresh cycle, reducing the risk of high-order multiple gestations (triplets or greater). The pregnancy success rates for cryopreserved embryos transferred into the human uterus can vary from practice to practice. Overall pregnancy rates at the national level with frozen embryos are lower than with fresh embryos. This, at least in part, results from the routine selection of the best-looking embryos for fresh transfer, reserving the "second-best" for freezing. There is some evidence that pregnancy rates are similar when there is no such selection.

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Acknowledgements Authors really acknowledge the hospital staff for helping to collect data for completion of this study. Reconstructing historical changes in the force of infection of dengue fever in Singapore: implications for surveillance and control. Prevalence of dengue among clinically suspected febrile episodes at a teaching hospital in North India. Time series analysis of dengue incidence in Guadeloupe, French West Indies: Forecasting models using climate variables as predictors. Clinical and biochemical characteristics of suspected dengue fever in an ambulatory care family medical clinic, Aga Khan University, Karachi, Pakistan. Delayed effects of weather variables on incidence of Dengue fever in Singapore from 2000-2010. Bioinformatics analysis of envelope glycoprotein e epitopes of Dengue virus type 3. Frequency and clinical presentation of dengue fever at tertiary care Hospital of Hyderabad/Jamshoro. The emergence and maintenance of vector-borne diseases in the Khyber Pakhtunkhwa Province, and the Federally Administered Tribal Areas of Pakistan, Frontior in Physiology, 2012; 3: 250. Entomological investigations of Dengue vectors in epidemic-prone districts of Pakistan during 2006­2010. Sajid A, Ikram A, Ahmed M, Dengue fever outbreak 2011: clinical profile of children presenting at madina teaching Hospital Faisalabad. Changing patterns and outcome of Dengue infection; report from a tertiary care hospital in Pakistan. Serotype and genotype analysis of dengue virus by sequencing followed by phylogenetic analysis using samples from three mini outbreaks2007-2009 in Pakistan. Phil, Institute of Microbiology, University of Agriculture, Faisalabad-38040, Pakistan and sadianasreen3@gmail. Second Author ­ Muhammad Arshad, PhD, Institute of Microbiology, University of Agriculture, Faisalabad-38040, Pakistan and drarshaduaf@gmail. Third Author ­ Muhammad Ashraf, PhD, Institute of Microbiology, University of Agriculture, Faisalabad-38040, Pakistan and mashraf@uaf. Phil, Institute of Pharmacy, Physiology and Pharmacology, University of Agriculture, Faisalabad-38040, Pakistan and ahmed. Phil, Institute of Microbiology, University of Agriculture, Faisalabad-38040, Pakistan and bharmsf@yahoo. Correspondence Author ­ Muhammad Ashraf, Institute of Microbiology, University of Agriculture, Faisalabad-38040, Pakistan. M Professor of Medicine Abstract- Introduction: Increased arterial pressure is one of the most important public health problem in developed as well as in developing countries. Left ventricular hypertrophy has been shown to be a common and surprisingly early finding in hypertension even in patients without the evidence of coronary artery disease. Studies have also shown that aggressive control of hypertension not only reduces the hypertrophy but also reduces the long term cardiovascular morbidity and mortality. Objectives: this study was undertaken to find out the incidence of left ventricular hypertrophy in hypertension. Materials and Methods: After careful exclusion of patients with secondary hypertension, valvular heart disease, Diabetes mellitus,gross congestive heart failure and ischemic heart disease, 85 patients were considered for the study. Coronary angiography was done in selected patients to rule out ischemic heart disease. In spite of increasing awareness in public and rapidly exapanding arrya of antihypertensive drugs, hypertension remains one of the major causes of cardiovascular morbidity and mortality(2). Burden of hypertension increases with age among individuals aged above 60 years, the prevalence is 65. Incidence of hypertension is 8-18% of adult population in developed countries and in India it is estimated to be between 15% in rural and 3-15% in urban population. Heart was traditionally regarded as a target organ adapting to the increased pressure load by hypertrophy and eventually failing if the load continues unremitted or was suddenly aggravated particularly if complicated by the advent of coronary disease.

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Japanese B encephalitis is endemic in Southeast Asia, whereas West Nile virus is found in west Asia, the Middle East, Africa, Central and Southern Europe and North America. Tick-borne encephalitis is endemic in some areas of forests and meadows in Central and Eastern Europe, and Asia. Louis encephalitis virus is found only in the Americas, whereas Murray Valley encephalitis virus is confined to British Medical Bulletin 2005;75 and 76 5 Chadwick Australia and New Zealand. The main host for these viruses are birds; however, pigs are also an important host for Japanese B encephalitis. There were also reports in that year, for the first time, of transmission through transfusions and organ transplants [18]. Most flaviviral infections are either asymptomatic or cause mild febrile illness without overt meningitis, with an incubation period of 5­15 days. The characteristic presentation of West Nile fever is arthralgia, rash and fever [19], whilst Japanese B encephalitis may present with abdominal pain or nausea and vomiting. Japanese B encephalitis is predominantly an encephalitis, whereas up to 40% of West Nile virus and St. Louis encephalitis infections (and 50% of Murray Valley encephalitis) present with meningitis. Tick-borne encephalitis, on the other hand, is a biphasic illness, with meningitis or encephalitis developing in a small proportion of patients a few days after the initial febrile illness subsides. Apart from the typical presentation of meningitis, many infections (especially in children) present with seizures or an altered level of consciousness; other complications of encephalitis such as hemiparesis or cranial nerve palsies may also occur. Two other neurological manifestations include a poliomyelitis-like syndrome, with features of flaccid paralysis, and a parkinsonian syndrome, reflecting the involvement of the anterior spinal cord and basal ganglia, respectively, in these infections. Severe neurological and systemic complications including death are more common in elderly adults, the immunocompromised and (for West Nile virus) diabetics. Around 50% of those with meningoencephalitis are left with long-term neurological disability or psychiatric sequelae. The tick-borne complex viruses, on the other hand, are a wellrecognized cause of meningoencephalitis in Central Europe and Asia, with the greatest incidence during the summer months. Several other insect-borne viruses (arboviruses) causing meningitis, particularly in the Americas, are described in the footnotes to Table 1. Meningoencephalitis and myo/pericarditis are the commonest serious complications Usually self-limiting; salivary gland swelling in around 50% Case fatality 4­13%, and higher amongst elderly, immunosuppressed and diabetics. Most frequently in children and non-immune adults Tick-borne infection contracted mainly in Europe and Asia; commonest in spring and early summer Develops in 5­10% of patients around or shortly after a seroconversion illness and occasionally during chronic infection Downloaded from academic. May present with stroke following zoster in elderly or with more diffuse chronic encephalitis in the immunocompromised a Includes polio, echoviruses and coxsackieviruses. Louis, Murray Valley, eastern, western and Venezuelan equine encephalomyelitis and California encephalitis. Meningitis is a more common manifestation than mumps encephalitis, typically associated with fever and vomiting; however, parotid or other salivary gland enlargement is only evident in around half of all cases. Very few of those affected develop complications such as encephalitis, neuropathies, myelitis or Guillain­Barrй syndrome, and mortality is rare. It is characteristically associated with a mononucleosis-like syndrome, with fever, lymphadenopathy, sore throat or a rash. A small proportion of cases progress to a chronic meningitis, sometimes complicated by cranial neuropathies or other focal signs. Other viruses A wide variety of other viruses are capable of causing meningitis; however, they are less commonly identified. Meningitis normally follows a non-specific prodromal illness, and in addition, patients may also report symptoms of pharyngitis and myalgia. An aseptic meningitis may complicate adenovirus, influenza and parainfluenza viral infections, and influenza vaccination has been associated with an acute aseptic meningitis. Although many other viruses are known to cause an acute meningoencephalitis, including 8 British Medical Bulletin 2005;75 and 76 Viral meningitis rhabdoviruses (rabies), parvovirus B19, Nipah and Hendra viruses (Morbillivirus), bunyaviruses and togaviruses, meningitis due to these infections is very rare, especially in Europe. A lymphocyte pleocytosis is often cited as a hallmark of viral meningitis, although a preponderance of polymorphs is sometimes seen early in the infection, particularly in enteroviral meningitis [2, 21].

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Four independent variables are tested on the project success and after running regression test above results are obtained which shows that Variables of Task Performance, Cognitive ability is insignificant at. The results show that Task proficiency has major impact on project success and Cognitive ability does not affect the Project success because it is showing an insignificant value after data analysis. The Performance is measured through Task Performance Behaviors and Contextual Performance Behaviors and it is concluded that Task and Contextual performance behaviors of Projects managers have positive impact on project Success. We have seen from the results of regression only two hypotheses have insignificant value at 5% significance level and remaining four have significant values at 5% significance level. The remaining variables four Cognitive ability, Job Knowledge, Task Proficiency and Experience make significant Impact on Project Success. Task performance behaviours were taken to check their role in the success of a project. Bailey (1987) suggested that the development of an appropriate conceptual model is main factor to identifying the relevant research methodology used to meet the objectives of the study. The identification of an appropriate theoretical framework was important to find out the appropriate measures which could identify the results required and development of the conceptual model paved the way towards fulfilling this objective. It was contended that, given that behaviors (as evident in the literature) are often stable and enduring over time, the operational measures which are involved can to a reasonable extent be assumed to be subjected to quantitative logic. Subsequently, in order to help establish the necessary convergence with similar studies on behavioral competencies, positivism was adopted as the underlying research paradigm that influenced the design of the research instrument. Development of a performance appraisal training programme for the rehabilitation institute of Chicago. Determinants of Innovative Behavior: A Path Model of Individual Innovation in the Workplace. The state of construction and infrastructure in sub-Saharan Africa and strategies for a sustainable way forward. It is a service through which messages (text only) can be transferred between mobiles. There are storage locations for the messages on mobile as well as on In this paper, I will be focusing on later one i. Below are some of the different behaviours that mobile phones implement: Some mobile phones delete the message by changing the status byte (first byte) to 00. This means that the data of message is still present only the record is being set as free space. And when there is any new incoming message this first byte will indicate this space as free space that can be used to store that new message. Thus if we say that the user wants to store last 10 incoming messages for recovering, then the number of records of the file(X) created should be 10. And in case the file(X) gets full then at this time on receiving new message the oldest message saved in file(X) will get replaced by the new one. So using this solution the recovering of message is possible regardless of the deletion behaviour. This application will be responsible for updating the status byte of messages to read/un-read from deleted. Thus, if the mobile phone updates only the status byte of message to 00 (deleted) then there is an option available to recover the same until a new message comes and over-rides this memory. Please note that this solution only works for the mobile phones having behaviour of updating the status byte for deletion and that too only till the time when no new incoming message over-rides that deleted message. Poovitha R*** Postgraduate Student, Department of Community Medicine, Sri Lakshmi Narayana Institute of Medical Sciences, Kudapakkam, Pondicherry 605 502, India ** Professor, Department of Community Medicine, Sri Lakshmi Narayana Institute of Medical Sciences, Kudapakkam, Pondicherry 605 502, India *** Statistician, Department of Community Medicine, Sri Lakshmi Narayana Institute of Medical Sciences, Kudapakkam, Pondicherry 605 502, India * Abstract- Background: the health status of people significantly depends upon their health related behavior life style. This study highlights the existing life style factors among incoming and outgoing medical students on their health status. Aims & Objectives: To determine and compare the eating habits and life style behaviors of the incoming and outgoing students. Methodology: this is a Cross sectional and Descriptive study conducted among the first M. Data was collected from 302 Students using a pretested semi open ended questionnaire, selfadministered to the students after obtaining their consent.

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A Bayesian System Integrating Expression Data with Sequence Patterns for Localizing Proteins: Comprehensive Application to the Yeast Genome. Genomwide analysis relating expression level with protein subcellular localisation. Detecting protein function and protein-protein interactions from genome sequences. Distinctive gene expression patterns in human mammary epithelial cells and breast cancers. Microarray analysis of the transcriptional network controlled by the photoreceptor homeobox gene Crx. Deletions of the short arm of chromosome 3 in solid tumors and the search for suppressor genes. Whole-genome trees based on the occurrence of folds and orthologs: implications for comparing genomes on different levels. Digging for dead genes: an analysis of the characteristics of the pseudogene population in the Caenorhabditis elegans genome. A comprehensive analysis of protein-protein interactions in Saccharomyces cerevisiae. Transposon mutagenesis for the analysis of protein production, function, and localization. The most common presenting signs are orbital and periorbital edema, eyelid retraction, eyelid lag in downgaze, restrictive strabismus, compressive optic neuropathy, and exposure keratopathy with common symptoms of ocular irritation and dryness (Figures 1 and 2) [1]. Note the periorbital edema, eyelid retraction, scleral show, and conjunctival injection. Both men and women demonstrate a bimodal pattern of age of diagnosis (40-44 and 60-64 years in women; 45-49 and 65-69 years in men). The median age of diagnosis is 43 years for all patients, with a range from 8-88 years. Orbital fibroblasts originate from neural crest cells and can differentiate into adipocytes or myofibroblasts [4]. In the active stage, there is active inflammation, which can lead to orbital muscle enlargement, conjunctival injection and chemosis, ocular pain, and swelling of the periocular tissues and eyelids. On average, the active phase lasts for 1 year in non-smokers and 2-3 years in smokers. The quiescent phase follows spontaneous resolution of the active phase (Figure 7). Lagophthalmos typically presents as dry eye, tearing, foreign body sensation, and blurred vision. This is an ophthalmologic emergency ­ the cornea is at risk for exposure, and the optic nerve is at risk of irreversible damage. Note the vertical misalignment of the eyes in primary gaze and the restrictive movement in upward gaze. Orbital tumors ­ Orbital tumors are typically unilateral in presentation and can cause proptosis and a wide variety of motility disturbances depending on location. IgG4 disease ­ Tumefactive lesions and fibrosis affecting one or more organs characterize this fibro-inflammatory disorder. It is most commonly present in the biliary tree, retroperitoneum, salivary glands, orbit, and lymph nodes. Orbital IgG4 disease often involves painless swelling of the extraocular muscles, lacrimal glands, and infraorbital nerves in combination with paranasal sinus disease. Both smoking cessation and euthyroidism help prevent further exacerbation and decrease the duration of active disease. In addition, research suggests optimizing selenium and vitamin D levels may be beneficial. Initiation of therapy during the final months of active inflammatory phase has little effect on the final outcome of disease. Once the chronic fibrotic stage has set in, treatment options become more limited, i. Propylthiouracil and methimazole, thiourea derivatives, are used for thyroid hormone suppression.

Syndromes

  • Regional anesthesia to numb your arm and shoulder area so that you do not feel any pain in this area. If you receive regional anesthesia, you will also be given medicine to help you relax during the operation.
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From 2001 to 2010, the hospitalization rate for stroke appeared to be higher for males than females. Black non-Hispanics and Hispanics experience disparities in risk factors for heart disease and stroke, 162,163 such as nutrition and physical activity. Black non-Hispanics had the highest stroke hospitalization rate, which was approximately 76% higher than that for white non-Hispanics. The stroke hospitalization rate for Hispanics was approximately 15% higher than that for white non-Hispanics. In 2011, the prevalence of diagnosed high blood pressure varied significantly by race and ethnicity, ranging from a low of 22. Approximately 3 in 10 white non-Hispanic adults were diagnosed with high blood pressure. The percent of adults ever told that they had high cholesterol did not vary significantly by race or ethnicity. The proportion of adults in 2011 ever told they had high blood pressure among those with a college degree (23. Although the percent of adults diagnosed with high cholesterol was inversely related to educational level, only the difference between those without a high school degree (43. Heart disease Stroke Source: Connecticut Department of Public Health, Hospitalization Table, 2010, Table H-2. In Connecticut, costs associated with health care, lost productivity, and premature mortality due to diabetes totaled $1. Diabetes is also a financial burden for persons with diabetes, whose medical expenditures are more 168 than double those of persons without diabetes. Diabetes is a risk factor for lower life expectancy, cardiovascular disease, stroke, kidney disease, vision loss, 169,170,171 amputations, and disability. While the diabetes mortality rate has declined since 2001, the proportion of Connecticut adults who have ever been told by a health care provider that they had diabetes increased. From 2000 to 2012, the proportion of adults ever told they had diabetes increased from a low of 5. Disparities From 2001 to 2010, the diabetes mortality rate was higher among males than females. The prevalence of diabetes has increased for those with a high school education or 173 less. The percent of adults ever told they have diabetes in Connecticut in 2012 ranged from 12. Diabetes-related emergency department visits differ by race and ethnicity, with black non-Hispanics and Hispanics having disproportionately higher rates of emergency department visits for diabetes than white non-Hispanics. The rate of diabetes-related emergency department visits for black non-Hispanics was 4. Prostate, 2,676, Lung and 27% Bronchus, 1,285, 13% Colon and Rectum, 858, 9% Breast, 3,078, 30% Lung and Bronchus, 1,307, 13% Colon and Rectum, 866, 9% Why Cancer is Important Females (N=10,097) Thyroid, 521, 5% Source: Connecticut Tumor Registry, Connecticut Department of Public Health. Cancer is the second leading cause of death in Connecticut, where 1 in 2 males and 1 in 3 females in will 174 be diagnosed with cancer at some point in their life. The majority of cancers are thought to be 175 associated with modifiable risk factors. Modifiable behavioral risk factors for cancer include smoking, physical inactivity, 178 poor nutrition, and ultraviolet light exposure. In 2010, cancer of the prostate, lung and bronchus, and colon and rectum contributed the greatest number of new cancer cases among males, followed by cancer of the urinary bladder and melanoma of the skin. For females, cancer of the breast, lung and bronchus, and colon and rectum comprised the largest number of new cancer cases in Connecticut in 2010, followed by cancer of the corpus and uterus and thyroid. In 2010, cancer of the lung and bronchus contributed the largest number of cancer deaths for male and female residents of Connecticut. For males, prostate cancer was the second leading cause of death due to cancer, followed by cancer of the colon and rectum. For females, breast cancer was the second leading cause of death due to cancer, followed by cancer of the colon and rectum. Disparities From 2008 to 2010, combined, the cancer incidence rate for all invasive cancers was significantly higher for white non-Hispanics relative to Hispanics and the difference between white non-Hispanics and black non-Hispanics was not significant. Compared to white non-Hispanics and Hispanics, the cancer mortality rate for all invasive cancers was significantly higher for black non-Hispanics.

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They were questioned about the relevance of biodiversity to real world issues and 91. Most of the student teachers are aware of the underlying issues and perspectives regarding the controversy in conservation of biodiversity. For example they were able to explain the controversy between the opinions of environmentalists and economists. This includes difference in opinion with regard to allowing activities that harm biodiversity to take place, illegal logging and the emphasis on development. They are also able to explain the decline of biodiversity as a result of development activities, deforestation, pollution and so on [3]. Biodiversity loss can cause human disease, lack of food and environmental disaster [14]. Even though some of them claim that they understand the relevance of biodiversity to real world issues, yet they are unable to provide further explanation when asked to give examples. Student teachers who can list specific examples of the importance of biodiversity to human societies show that they Knowledge about biodiversity is essential since human activities have affected the balance of biodiversity in the world. Thus Biodiversity Education is important to educate the public and promote awareness of biodiversity. Therefore, the ability to define biodiversity seems important to ensure proper understanding of the topic. Definition of Biodiversity When asked whether they can define the term biodiversity, 93. Five aspects emerged from the definition of biodiversity given by the student teachers. These are diversity, living things, species diversity, genetic diversity and ecosystem diversity. Aspects of genetic diversity were also not directly stated in the definition of biodiversity. Fiebelkorn and Menzel [11] also found that the teacher ignores genetic diversity as part of biodiversity and are often unable to explain the difference between species diversity and genetic diversity. Biodiversity may be considered at three levels which is genetic diversity, species diversity and ecosystem diversity. Based on the definition given by student teachers, about 54% of them can define biodiversity very generally as the variability among living organisms. For example, they know that biodiversity is the source of food, both for humans and animals. They also stated that biodiversity functions as a source of other needs of living organisms, such as oxygen, habitat and medicine. They commented that biodiversity is necessary for the continuation of the energy cycle. They can even provide examples of the species that is used to provide medicine, such as the Bitangor tree. From the answers given, student teachers can relate biodiversity with economic development, social development and environment. It is also agreed by [15] and [7] that biodiversity education is related with social relationships and the environment. Respondents in this study (85%) indicate that they knew the strategy to protect biodiversity and ways to promote the importance of biodiversity to society. Some of them also suggest that we need to explore biodiversity around us to enable others to understand the concept of biodiversity. Exploring the forest, different habitats and visit to gardens are also suggested as ways to provide experience about biodiversity. Campaigns through social and mass media are also recommended as alternative ways to promote biodiversity.

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Smokeless Tobacco and Public Health: A Global Perspective Illustrations Tables Table 2-1 Table 2-2 Table 2-3 Table 2-4 Table 3-1 Table 3-2 Table 3-3 Table 3-4 Table 3-5 Table 3-6 Table 4-1 Table 4-2 Table 4-3 Table 5-1 Table 5-2 Table 5-3 Table 5-4 Table 5-5 Table 5-6 Table 5-7 Table 5-8 Table 5-9 Table 5-10 Data sources on prevalence of smokeless tobacco use and related indicators among youth and adults. The editors thank the many scientists who provided critical reviews of the content of all or part of this report. Associate Professor Department of Community Dentistry Faculty of Health Sciences University of Pretoria Pretoria, South Africa the authors of chapter 6 acknowledge Maansi Bansal-Travers and Kaila Norton for their contributions. Director, Health Promotion and Tobacco Control Adjunct Assistant Professor Public Health Foundation of India New Delhi, India Jon O. Professor of Community Oral Health Queen Mary University of London London, United Kingdom Hans Giljam, M. Professor Department of Public Health Sciences Karolinska Institutet Stockholm, Sweden the authors of chapter 10 acknowledge Manu Dahiya, Siddharth Shanbhag, and Ann McNeill for their contributions. Associate Professor Department of Community Dentistry Faculty of Health Sciences University of Pretoria Pretoria, South Africa Masego Rantao, M. Lecturer, Department of Community Dentistry Faculty of Health Sciences University of Pretoria Pretoria, South Africa Chapter 13 Ghazi Zaatari, M. Professor, Oral Pathology, Epidemiology and Biostatistics Director, Research and International Relations College of Dentistry Jazan University Jazan, Saudi Arabia Prakash Gupta, D. Ray Senior Research Assistant Healis­Sekhsaria Institute for Public Health Mumbai, India Dhirendra N. Tobacco Free Initiative Regional Office for South-East Asia World Health Organization New Delhi, India xviii Smokeless Tobacco and Public Health: A Global Perspective Chapter 14 Annette M. Adjunct Research Faculty Cancer Research Center, University of Guam Mangilao, Guam Clinical Associate Professor Cancer Research Center of Hawaii, University of Hawaii at Manoa Honolulu, Hawaii Reviewers Mira B. Behavioral Scientist Communication Expert International Union against Tuberculosis and Lung Disease (The Union) New Delhi, India Olalekan A. Associate Professor Department of Community Dentistry Faculty of Health Sciences University of Pretoria Pretoria, South Africa Stephen Babb, M. Health Policy and Systems Advisor Health Sector Development World Health Organization Beijing, China Raman Bedi, D. Director Tobacco Free Initiative World Health Organization Geneva, Switzerland Rajani Bhisey, Ph. Professor of Community Oral Health Queen Mary University of London London, United Kingdom Manu Dahiya, M. Queen Mary University of London Barts and the London School of Medicine and Dentistry Institute of Dentistry London, United Kingdom Cristine Delnevo, Ph. Professor of Psychology Department of Psychology University of Waterloo Ontario, Canada Rajani George, M. Director, Cancer Science and Trends Director, International Cancer Control American Cancer Society, Inc. Professor, Oral Pathology, Epidemiology and Biostatistics Director, Research and International Relations College of Dentistry Jazan University Jazan, Saudi Arabia Javaid A. Sackler Faculty of Medicine School of Public Health Tel Aviv University Tel Aviv, Israel Jonathan M. Senior Officer Medical Research Public Health and Policy Health Authority Abu Dhabi, United Arab Emirates Siddharth Shanbhag, M. Queen Mary University of London Barts and the London School of Medicine and Dentistry Institute of Dentistry London, United Kingdom Surendra S. Tobacco Free Initiative Regional Office for South-East Asia World Health Organization New Delhi, India Stephen A. Senior Adviser on Tobacco Product Regulation, Legislation, and Enforcement Tobacco Free Initiative World Health Organization Geneva, Switzerland Ghazi Zaatari, M. Lisa Adams, Graphic Artist Elmer Alcantara, Graphic Artist Allyson Austin, Copy Editor Holly Bowers, Copy Editor Julie Bromberg, M. Behavioral Risk Factor Surveillance System Centers for Disease Control and Prevention confidence interval Commonwealth of the Northern Mariana Islands Conference of the Parties Canadian Tobacco Use Monitoring Survey Demographic and Health Surveys European Commission European Union Framework Convention on Tobacco Control U.

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Aminocaproic Acid (also known as Amicar, -aminocaproic acid, or 6-aminohexanoic acid) Aminocaproic acid is an anti-fibrinolytic. Indications: Treatment of excessive post-operative bleeding Reduce blood loss during coronary bypass Treatment of bleeding associated with administration of thrombolytic drugs Prevention of bleeding in patients with severe, chronic thrombocytopenia A recent clinical trial showed that administration of tranexamic acid to trauma patients within 3 hours of injury decreased the likelihood of death from bleeding 2. Vitamin K Several of the coagulation factors are vitamin K-dependent for their production. Describe the relationship between platelet count and bleeding risk in conditions associated with decreased production or increased destruction of platelets. Describe the pathophysiology, genetics, and the clinical and laboratory characteristics of hemophilia A and B. Describe the pathophysiology of Vitamin K deficiency, and list several causes of this condition. Be able to explain how to use laboratory tests to distinguish coagulation factor deficiency from an inhibitor of coagulation. Approach to the Patient with a Possible Bleeding Disorder Although the discussion of bleeding disorders frequently emphasizes laboratory testing, the patient history is often the most informative tool in the evaluation of these disorders. The history can provide clues as to whether a clinically significant bleeding diathesis is present, what type of defect is likely, and whether this represents a hereditary or acquired condition. Examination of the skin, oropharynx, abdomen, and joints may suggest the type of defect and severity of the suspected disorder. Thus, a careful history and physical exam will often focus the subsequent laboratory evaluation and choice of therapy. In general, bleeding limited to the skin and mucosal surfaces suggests thrombocytopenia or a defect in platelet or von Willebrand factor function (primary hemostasis). Development of oral mucosal "blood blisters" is usually an indication of clinically severe thrombocytopenia. Deep tissue bleeding, on the other hand, suggests a defect in the soluble coagulation factor response (secondary hemostasis). Retroperitoneal bleeding or hemarthrosis are particularly associated with defects in secondary hemostasis. Inquire about excessive or spontaneous bruising, nosebleeds (epistaxis) and gum bleeding, hematemesis, blood in the urine (hematuria) or stool (hematochezia, melena), and unusually heavy or prolonged menstrual flow (menorrhagia). Has the patient had previous hemostatic challenges, including surgery, major trauma, or tooth extractions? Have they previously received blood products or been treated with chronic iron replacement? Skin- Petechiae (pinpoint bleeding in skin), generalized purpura or ecchymoses (larger bruising), perifollicular purpura (scurvy), striae, and telangiectasias. Very large ecchymoses are often pathologic, especially when they occur spontaneously in the absence of trauma. Oral mucosa- Palatal petechiae, buccal mucosal hematomas or "blood blisters", gum bleeding, and telangiectasias. In particular, "blood blisters" on the buccal mucosa suggest severe thrombocytopenia. Splenomegaly- An enlarged spleen will sequester platelets, and may be a sign of underlying liver disease. Joint deformities- Chronic arthropathy may indicate moderate or severe hemophilia. Laboratory Evaluation (see Chapter 11 for descriptions of individual tests) the laboratory evaluation should be guided by the clinical history. Our ability to detect coagulation defects in the laboratory is generally quite good. In contrast, our ability to assess fibrinolysis is only fair, and assessment of platelet function is relatively crude due to the complex nature of the platelet response. Inherited Bleeding Disorders A significant body of knowledge exists regarding the genetics and physiology of human bleeding disorders. These conditions are relatively common because they are either X-linked (in the case of the hemophilias) or dominantly inherited (most forms of von Willebrand disease). Likewise, inherited defects in platelet production and function are relatively rare. These disorders both demonstrate X-linked inheritance, and the severity of the phenotype depends on specific factor activity (<1% activity = severe, 1-5% activity = moderate, 5-30% activity = mild). Severe hemophiliacs demonstrate spontaneous bleeds into joints and deep tissue and require factor replacement on an ongoing basis.

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Administer corticosteroids (initial dose of 1 to 2 mg/kg/day prednisone or equivalent followed by a taper) for Grade 2 or greater colitis. Thirty-three (69%) of the 48 patients received systemic corticosteroids, with 27 of the 33 requiring high-dose corticosteroids for a median duration of 7 days (range: 1 day to 5. Thirteen (68%) of the 19 patients received systemic corticosteroids, with 12 of the 13 receiving high-dose corticosteroids for a median duration of 5 days (range: 1 to 26 days) followed by a corticosteroid taper. Consider more frequent monitoring of liver enzymes as compared to when the drugs are used in monotherapy. Monitor for signs and symptoms of hypophysitis (including hypopituitarism and adrenal insufficiency). Sixteen (94%) of the 17 patients received systemic corticosteroids, with 6 of the 16 receiving high-dose corticosteroids. Monitor patients for changes in thyroid function (at the start of treatment, periodically during treatment, and as indicated based on clinical evaluation) and for clinical signs and symptoms of thyroid disorders. Administer replacement hormones for hypothyroidism and manage hyperthyroidism with thionamides and beta-blockers as appropriate. Administer corticosteroids (initial dose of 1 to 2 mg/kg/day prednisone or equivalent followed by a taper) for Grade 2 or greater nephritis. Eight (89%) of the 9 patients received systemic corticosteroids, with 7 of the 8 receiving high-dose corticosteroids for a median duration of 15 days (range: 3 days to 4. For suspected immune-mediated adverse reactions, ensure adequate evaluation to confirm etiology or exclude other causes. Upon improvement to Grade 1 or less, initiate corticosteroid taper and continue to taper over at least 1 month. Based on limited data from clinical studies in patients whose immune-related adverse reactions could not be controlled with corticosteroid use, administration of other systemic immunosuppressants can be considered. Monitor patients for signs and symptoms of infusion-related reactions including rigors, chills, wheezing, pruritus, flushing, rash, hypotension, hypoxemia, and fever. Among the 2799 patients, 41% were exposed for 6 months or more and 21% were exposed for 12 months or more. Patients with active autoimmune disease or a medical condition that required immunosuppression or mucosal or ocular melanoma were ineligible. The study population characteristics were: median age of 64 years (range: 34 to 84), 49% age 65 years or older, 59% male, 94% White and 3% Asian, and 18% with history of brain metastases at baseline. Patients with autoimmune disease that required systemic therapy within 2 years of treatment; a medical condition that required immunosuppression; or who had received more than 30 Gy of thoracic radiation within the prior 26 weeks were ineligible. A total of 139 of 203 patients (68%) received paclitaxel and 64 patients (32%) received paclitaxel protein-bound in combination with carboplatin. The study population characteristics were: median age of 65 years (range: 40 to 83); 52% age 65 or older; 78% male; 83% White; and 9% with history of brain metastases. The most frequent (2%) serious adverse reactions were febrile neutropenia (6%), pneumonia (6%), and urinary tract infection (3%). The study population characteristics were: median age of 63 years (range: 25 to 90), 45% age 65 years or older; 71% male; 64% White, 30% Asian, and 2% Black. The most frequent (2%) serious adverse reactions were pneumonia (7%), pneumonitis (3. Patients with autoimmune disease, medical conditions that required systemic corticosteroids or other immunosuppressive medication, or who had received more than 30 Gy of thoracic radiation within the prior 26 weeks were ineligible. The study population characteristics were: median age of 63 years (range: 20 to 88), 42% age 65 years or older, 61% male, 72% white and 21% Asian, 8% with advanced localized disease, 91% with metastatic disease, and 15% with history of brain metastases. Twenty-nine percent received two or more prior systemic treatments for advanced or metastatic disease. The median age of patients was 60 years (range: 20 to 84), 35% were age 65 years or older, 83% were male, 77% were White, 15% were Asian, and 5% were Black. Sixty-one percent of patients had two or more lines of therapy in the recurrent or metastatic setting, and 95% had prior radiation therapy. The most frequent serious adverse reactions reported in at least 2% of patients were pneumonia, dyspnea, confusional state, vomiting, pleural effusion, and respiratory failure.

References:

  • https://www.nationalmssociety.org/NationalMSSociety/media/MSNationalFiles/Brochures/Clinical_Bulletin_Corticosteroids-in-Management-of-MS.pdf
  • https://www.accessdata.fda.gov/drugsatfda_docs/nda/2015/206316Orig1Orig2s000MedRedt.pdf
  • https://i.4pcdn.org/tg/1459425390888.pdf
  • https://www.bjournal.org/wp-content/uploads/articles_xml/1414-431X-bjmbr-S0100-879X2003000100003/1414-431X-bjmbr-S0100-879X2003000100003.x72422.pdf
  • https://www.sciencedirect.com/science/article/pii/S0085253815600667/pdf?md5=d0f4b96a86820656de7dadee6cc610ef&pid=1-s2.0-S0085253815600667-main.pdf
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