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The clinician is most cautious about providing services that would be particularly stressful for the patient blood pressure 40 over 20 proven digoxin 0.25mg. Table 5-4 lists the risk of systemic complications associated with some common dental procedures heart attack olivia newton john order digoxin overnight delivery. Systemic therapy blood pressure medication depression discount digoxin 0.25 mg line, in contrast, focuses on the entire patient with the goal of delivering dentistry safely and comfortably. Other techniques are instituted to effect behavioral changes, for example, smoking cessation instruction or instruction in diet modification. The dentist must assess the patient before, during, and after treatment to determine if any of these therapies is indicated. Postponing or Limiting Treatment Deciding whether it is in the best interest of the patient to limit or postpone dental care is always a difficult decision. Consider, for example, the patient scheduled for periodontal surgery whose blood pressure registers at 170/110 mm Hg. Such a finding would be a clear indication for postponing the procedure so that the patient can seek medical consulta- 100 Phases of the Treatment Plan tion. Other situations in which it may be advisable to delay treatment include the patient who is not feeling well, is extremely anxious, or has a health condition that requires immediate medical attention. Managing the patient with significant systemic problems or abnormal vital signs and an acute dental problem, such as severe pain associated with an irreversible pulpitis, presents particular difficulties. It may be necessary to provide limited therapy, such as initiating root canal therapy or prescribing an antibiotic, and analgesic drugs for pain control. First, a physician may be contacted to request physical evaluation and treatment for the patient when signs of systemic disease are first discovered in the dental office. In this situation, a written consult is most useful, particularly if the patient currently does not have a regular physician (see In Clinical Practice). For example, a patient might be referred for treatment of hypertension, with a letter that contains the most recent blood pressure measurements and a request to evaluate and treat. In Clinical Practice Writing a Referral Letter the referral letter to a physician must contain the following three items: 1. The proposed dental treatment, including some indication of how physically stressful the treatment may be; a listing of drugs (anesthetics/analgesics) proposed to be used during and after the treatment also may be included 2. A request for a disclosure of contraindications, precautions, and/or medication changes that the physician recommends Remember that the dental treatment of the patient is your responsibility. You should not expect the physician to accept that responsibility or dictate treatment. She reports that she has recently begun to take a prescribed oral hypoglycemic drug daily, but was uncertain of the medication name and dosage. Roe will require in-office periodontal surgery in both the upper and lower arches of her mouth. The surgery will entail local anesthetic (2% lidocaine with a vasoconstrictor) and a narcotic analgesic for postoperative pain. The surgery will involve the reflection of both buccal and palatal or lingual gum tissue and mechanical bone remodeling. Although numerous intraoral sutures will be required, most patients do not experience postoperative discomfort at a level that would preclude a regular diet. In your opinion, are there any precautions or contraindications to the proposed dental treatment? Finally, are there any other medical considerations of which I should be aware that Ms. Should you require any additional information, please do not hesitate to contact me. Finally a dentist may need input from the physician to help determine whether providing dental treatment In Clinical Practice Consulting a Physician by Telephone Often the most expeditious method for consulting with a physician, especially when the patient has both significant health problems and urgent dental needs, is a telephone call. Because patients may receive care from a number of physicians, the dentist must first confirm who is the best physician to call. It may be necessary to fax ahead a form signed by the patient permitting the physician to discuss his or her health information. Although some practitioners delegate some straightforward consultations to the dental hygienist, ideally the dentist should place the call. Writing specific questions out beforehand helps ensure that all necessary information is obtained. All significant systemic diagnoses and any medications the patient may be taking should be verified. Although unnecessary detail concerning the proposed dental treatment should be avoided, the physician should be informed about anticipated levels of stress, blood loss, and possible postoperative problems. With questions to the physician that are clear and to the point, the dentist should gain sufficient information to reshape plans for treatment appropriately. All other new information should be documented in the patient record immediately after the telephone call. For example, consider the patient with many health concerns, who is under treatment by several medical specialists. Unless one physician is coordinating care, the dentist may need to discuss the situation with several physicians, gathering information and opinions to help determine what course should be taken. This does not involve asking permission to provide dental care, but rather is a collegial discussion of the proposed treatment plan and the risks and benefits it brings to the patient. The desired outcome of the conversations is a mutual decision regarding what treatment can and should be provided, and how the care can be delivered to minimize patient health risks. If there is no answer to a written consultation request, the dentist will want to confirm, usually by telephone, that the physician did indeed receive it. The dentist may first wish to determine whether a correct mailing address was used or, if the request was to be hand-carried by the patient, confirm that the patient actually visited the physician. Occasionally the physician will return a written request with an unclear response or one that the dentist may not agree with. Stress Management Many patients find visiting the dentist an anxiety-provoking experience. A detailed discussion of the manifestations and implications of anxiety is presented in Chapter 13. Helping the patient cope with stress represents one of the most beneficial systemic treatments a dentist can provide. This is particularly true for patients with such systemic problems as cardiac disease, diabetes, and adrenocortical insufficiency. Stressful events have a physiologic effect on the body, primarily because of the release of a class of substances called catecholamines, which include epinephrine and norepinephrine. Imagine, for a moment, how an anxious but physically healthy patient is affected by stress. The stressful experience often begins with a loss of sleep for one or more days before the dental appointment.
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A randomised blood pressure ranges nhs digoxin 0.25 mg low price, double-blind study comparing the efficacy and tolerability of controlled-release doxazosin and tamsulosin in the treatment of benign prostatic hyperplasia in Brazil hypertension questions buy cheap digoxin line. A novel spectral ultrasonic differentiation method for marking regions of interest in biological tissue: in vitro results for prostate arteria coronaria buy digoxin online. Lower urinary tract symptoms, urinary incontinence, sexual function and quality of life after radical prostatectomy and external beam radiation therapy: real life experience in Austria. Re: Sildenafil citrate improves erectile function and urinary symptoms in men with erectile dysfunction and lower urinary tract symptoms associated with benign prostatic hyperplasia: a randomized, double-blind trial: K. Prevalence and risk factors for erectile dysfunction in 2869 men using a validated questionnaire. The association between lower urinary tract symptoms and renal function in men: a cross-sectional and 5-year longitudinal analysis. The association between vascular risk factors and lower urinary tract symptoms in both sexes. Retrograde endopyelotomy: a comparative study of hot-wire balloon and ureteroscopic laser. Can prolonged treatment improve the prognosis in adults with focal segmental glomerulosclerosis. Clinical significance of alpha1-adrenoceptor selectivity in the management of benign prostatic hyperplasia. A comparison between the response of patients with idiopathic detrusor overactivity and neurogenic detrusor overactivity to the first intradetrusor injection of botulinum-A toxin. Testosterone gel supplementation for men with refractory depression: a randomized, placebo-controlled trial. Nephrogenic adenoma of the urinary bladder: our experience and review of the literature. Impact of early pelvic floor rehabilitation after transurethral resection of the prostate. Absence of lower urinary tract symptoms is an independent predictor for cancer at prostate biopsy, but prostate-specific antigen is not: results from a prospective series of 569 patients. Ureteroscopic laser lithotripsy for upper urinary tract calculi with active fragment extraction and computerized tomography followup. Atrophy in prostate needle biopsy cores and its relationship to prostate cancer incidence in screened men. Association of ureaplasma urealyticum with abnormal reactive oxygen species levels and absence of leukocytospermia. Transurethral electrovaporization vs transurethral resection for symptomatic prostatic obstruction: a meta-analysis. Erectile dysfunction after transurethral prostatectomy for lower urinary tract symptoms: results from a center with over 500 patients. A randomized, double-blind, placebo-controlled trial to determine the effectiveness of botanically derived inhibitors of 5-alpha-reductase in the treatment of androgenetic alopecia. Symptomatic and asymptomatic benign prostatic hyperplasia: molecular differentiation by using microarrays. Elevated serum procalcitonin values correlate with renal scarring in children with urinary tract infection. Potential mechanisms of action of superselective alpha(1)-adrenoceptor antagonists. The dynamics of prostate-specific antigen in benign and malignant diseases of the prostate. The uristatin dipstick is useful in distinguishing upper respiratory from urinary tract infections. Stimulation of Hyaluronan synthetase by platelet-derived growth factor bb in human prostate smooth muscle cells. Demethylation-linked activation of urokinase plasminogen activator is involved in progression of prostate cancer. Impact of age, benign prostatic hyperplasia, and cancer on prostate-specific antigen level. Do we know everything about alpha-blockade in the management of lower urinary tract symptoms. Concurrent serious bacterial infections in 2396 infants and children hospitalized with respiratory syncytial virus lower respiratory tract infections. Expression of thyroid hormone receptors is disturbed in human renal clear cell carcinoma. Long-term clinical and biologic effects of the lipidosterolic extract of Serenoa repens in patients with symptomatic benign prostatic hyperplasia. Chromatofocusing fractionation and two-dimensional difference gel electrophoresis for low abundance serum proteins. Boosted decision tree analysis of surface-enhanced laser desorption/ionization mass spectral serum profiles discriminates prostate cancer from noncancer patients. Factors affecting health-related quality of life among patients with lower urinary tract symptoms. Reliability and validity of the Malay version of the Health-Related Quality of Life instrument in a Malaysian population. Page 189 132320 119280 153070 101390 138270 118440 136320 163470 154470 121310 111650 125290 102200 104400 113520 127470 135960 September 2010 Appendix 3: Master Bibliography American Urological Association, Inc. Construction of the Mandarin version of the International Prostate Symptom Score inventory in assessing lower urinary tract symptoms in a Malaysian population. Quality of life assessment before and after transurethral resection of the prostate in patients with lower urinary tract symptoms. The effects of treating lower urinary tract symptoms on health-related quality of life: a short-term outcome. The male marital satisfaction following treatment for lower urinary tract symptoms. The sensitivity of the Malay version of Brief Manual of Sexual Function Inventory in assessing erectile dysfunction secondary to benign prostatic hyperplasia. Reliability and validity of the International Prostate Symptom Score in a Malaysian population. Reliability and validity of the Malay version of the International Prostate Symptom Score in the Malaysian population. Effect of treating lower urinary tract symptoms on anxiety, depression and psychiatric morbidity: a one-year study. Page 190 136970 136940 134660 134260 135630 108450 133970 117070 137690 120390 130460 136630 136710 130770 131550 130310 111220 September 2010 Appendix 3: Master Bibliography American Urological Association, Inc. Successful in utero endoscopic ablation of posterior urethral valves: a new dimension in fetal urology.
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American College of Cardiology/American Heart Association perioperative assessment guidelines for noncardiac surgery reduces cardiologic resource utilization preserving favorable outcome define pulse pressure quizlet buy digoxin with mastercard. Preoperative cardiac risk assessment for noncardiac surgery: defining costs and risks pulse pressure 72 purchase digoxin toronto. American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization pulse pressure meaning proven 0.25 mg digoxin. An evaluation of the clinical and cost-effectiveness of pulmonary artery catheters in patient management in intensive care: a systematic review and a randomized controlled trial. Clinical and economic effects of pulmonary artery catheterization in nonemergent coronary artery bypass surgery. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Outcomes using lower versus higher hemoglobin thresholds for red blood cell transfusion. Transfusion threshold and other strategies for guiding allogeneic red blood cell transfusion. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Colloid versus crystalloid for fluid resuscitation in critically ill patients (Review). Physicians should consider multimodal therapy, including non-drug treatments such as behavioral and physical therapies prior to pharmacological intervention. Patients should be informed of the risks of such treatment, including the potential for addiction. Physicians and patients should review and sign a written agreement that identifies the responsibilities of each party. Physicians should proactively evaluate and treat, if indicated, the nearly universal side effects of constipation and low testosterone or estrogen. Imaging for low back pain in the first six weeks after pain begins should be avoided in the absence of specific clinical indications. Most low back pain does not need imaging and doing so may reveal incidental findings that divert attention and increase the risk of having unhelpful surgery. Intravenous sedation can be used after evaluation and discussion of risks, including interference with assessing the acute pain relieving effects of the procedure and the potential for false positive responses. American Society of Anesthesiologists Standards for Basic Anesthetic Monitoring should be followed in cases where moderate or deep sedation is provided or anticipated. Irreversible interventions for non-cancer pain, such as peripheral chemical neurolytic blocks or peripheral radiofrequency ablation, should be avoided because they may carry significant long-term risks of weakness, numbness or increased pain. Committee members submitted potential recommendations for the campaign, and from this list voted on which recommendations should be included in the final "Top 5 List. The Committee communicated electronically and met in person during the development and approval process. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain [Internet]. Prevention of opioid abuse in chronic non-cancer pain: an algorithmic, evidence based approach. Continuous opioid treatment for chronic noncancer pain: a time for moderation in prescribing. The role of radiography in primary care patients with low back pain of at least 6 weeks duration: a randomized (unblended) controlled trial. Cost-effectiveness of lumbar spine radiography in primary care patients with low back pain. American Society of Anesthesiologists Task Force on Chronic Pain Management, American Society of Regional Anesthesia and Pain Medicine. Is immediate pain relief after a spinal injection procedure enhanced by intravenous sedation? The effect of sedation on diagnostic validity of facet joint nerve blocks: an evaluation to assess similarities in population with involvement in cervical and lumbar regions. An update of evaluation of intravenous sedation on diagnostic spinal injection procedures. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. As physicians, anesthesiologists are responsible for administering anesthesia to relieve pain and for managing vital life functions, including breathing, heart rhythm and blood pressure, during surgery. After surgery, they maintain the patient in a comfortable state during the recovery and are involved in the provision of critical care medicine in the intensive care unit. These tests are helpful in selected patients, including those with early stage hormone receptor positive cancers with low scores on 21 gene recurrence testing, who can safely omit chemotherapy. These tests should not be done in patients who indicate the test results would not change their choice of treatment. Patients undergoing partial breast removal (lumpectomy) of the breast for invasive cancer benefit from re-operation to excise more breast tissue if microscopic review of the lumpectomy breast tissue indicates cancer cells at the tissue edge. However, if cancer cells are close to the edge, but not at the actual edge, then re-operation is not mandatory but can be considered on a case-by-case basis. After a new diagnosis of breast cancer in a single breast, many patients desire removal of both breasts, believing their cancer risk in the other breast is high and their cancer cure rate will be improved with double mastectomy. Double mastectomy should not be routinely performed in these patients until they have been provided with adequate understandable information about the generally low risk they will develop cancer in the other breast and the minimal effectiveness, if any, of double mastectomy improving their life expectancy. These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Committee members were provided with a full description of the Choosing Wisely campaign and its goals, as well as its emphasis on decreasing unnecessary tests and interventions. Specific recommendations were made to consider domains of care that reflected appropriateness, waste and value as noted in recent publications, randomized trials and meta-analysis. Committee members were instructed to rank candidate choices specifically as follows: Rank for appropriateness and value of care; value to be defined by quality of care in the numerator and burdens of care in the denominator. Burdens would include cost of care and non-cost patient burdens of care, such as the unnecessary need for a second surgery or a procedure or a test. Each candidate choice was ranked on a scale of 19 where 1 meant the statement had no value or importance and was not appropriate for a patient and 9 meant it had the highest possible value, importance and appropriateness. Panelists were asked to score by their opinion, not how they thought other surgeons or experts would score it. After each round of ranking, a spreadsheet with ranking results was provided to committee members. An individual person data meta-analysis of preoperative magnetic resonance imaging and breast cancer recurrence. Preoperative magnetic resonance imaging in breast cancer: meta-analysis of surgical outcomes.
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This shows just how debilitating the effects of severe depression can be on the brain blood pressure medication raynaud's disease discount digoxin 0.25 mg with visa. Sackeim just published another study in the journal Neuropsychopharmacology (February 2007) confirming his previous findings blood pressure chart low to high order digoxin with a visa. Specifically blood pressure medication used for sleep buy digoxin overnight delivery, data show that patients respond positively to medications 40% to 70% of the time but may require several trials of different medications. By contrast, medications usually take six to eight weeks for improvements to become apparent. They did so by administering a questionnaire known as the Medical Outcomes Study Short Form-36, which measures physical functioning, vitality, emotional and physical health, mental health, bodily pain, and general health. Most found the experience neutral or pleasant, and 54% considered a trip to the dentist more distressing. The informed consent documents we use at Johns Hopkins can be reviewed on pages 3335. This is controlled by beta-blockers and nitroglycerin administered by the anesthesiologist. The same holds true for people with glaucoma, for which intraocular pressure (which is related to blood pressure) is an issue. This is an issue because patients are not allowed anything to eat or drink after midnight the night before treatment. Consequently, we have to adjust their dose of insulin or oral hypoglycemics (to half or perhaps none) before treatment. We monitor the fetal heart rate before and after the procedure, and the patient of course consults with an obstetrician. Her sleep was disturbed, and she had neither the energy nor the interest to participate in her usual social activities with her church group. After several months of feeling this way, her primary care physician started her on 20 mg a day of fluoxetine (Prozac). A precipitous worsening of her symptoms followed, and she became unable to leave her house, feeling convinced that her sister- who was in good health-was in imminent danger of dying. Soon, she would not eat without a great deal of encouragement, and she needed help with basic daily activities, such as bathing. Believing that she could not be safely treated at home, her physician referred her to the hospital for inpatient treatment. However, she continued to exhibit severe symptoms of depression, including marked changes in her mood, sleep, appetite, energy, and ability to interact with others. Both the patient and her family were initially wary of this treatment, mainly because of what they had read and seen in old movies. They explained that memory difficulties are usually short term and primarily affect the period just before and just after treatment. After three treatments, she had increased her ability to participate in daily activities, dressing herself and interacting with her family. The patient was slowly restarted on nortriptyline and released from the hospital when the dose of the antidepressant reached therapeutic levels. She is continuing to take nortriptyline and has periodic blood tests to check that her dose remains therapeutic. She sees her psychiatrist regularly- every four to six weeks-to monitor symptoms and medications. A pulsed high-intensity current is passed through the coil into specific areas of the brain, creating a powerful and focused magnetic field that changes the way brain cells function. Disaster episodes affect millions of people and exert a collective social suffering that requires a monumental effort by individuals, communities, societies, and the world community to overcome. Classically, relief efforts focus on the physical consequences of disasters by providing immediate medical attention and addressing health and environmental services (water supply, sewage disposal, and shelter). Only in recent years have the short and long-term consequences on mental health and psychosocial well being of individuals, families and communities been taken into consideration. By definition, coping with a disaster challenges individual and community adaptive capacity. Children and adolescents are emotionally vulnerable to their experiences during a disaster. Therefore, identification of intense and problematic responses needs to be followed by adequate support and treatment, according to the emotional needs and developmental stage of each child and taking the social supportive networks in consideration. Interventions to promote emotional wellbeing and to protect children against adverse outcomes should be informed by a resilience perspective and can often consist of strengthening supportive factors in social ecology of the child. Paramount is to restore safety and routine in the life of the child, and promote a sense of agency and self-efficacy. Such interventions can consist of educating adults who provide care (parents, teachers, pediatricians, and other professional staff) about how to help a distressed child, and how to differentiate between normal and abnormal adaptive reactions. Knowing when to intervene is important, because adverse experiences during childhood are associated with a higher risk of later emotional and behavioral disorders. On the other hand, well intended interventions at the wrong time can disturb the natural healing and recovery and make things worse. Interventions need to be situated in a multilayered response system that works on various levels, such as individual support for those who need it, as well as strenghtening family and community support mechanisms. Many useful interventions can and should be done by nonspecialists since the availability of pediatric mental health professionals is often limited, especially in low and middle income countries, Even high income countries may lack specialists in rural areas, and disasters may disrupt access or overwhelm resources even where the supply is nominally adequate. Training pediatricians, nurses, other professional staff and school based staff has the potential to greatly enhance the effective management, early intervention, and support for children and families affected by a disaster, so that the majority of impacted children will adjust and recover functioning. This module provides information on the emotional consequences of exposure to massive incidents among children and adolescents. This module describes the criteria for the identification of more serious mental health disorders, and proposes strategies for the referral and management of children at different developmental stages. If not physically impaired by the disaster, most children will be able to resume normal play, educational, and other developmentally appropriate activities. Degree of Dependency on Adults in the Family or Caregivers Infants, toddlers, and preschoolers are nearly completely dependent on adults for their care. Adolescents, while less dependent, may lack experience Vulnerability also depends on individual characteristics of the child, the social and economic circumstances of the family, community, and the available resources in the surrounding environment. The human impact of a disaster is affected by the vulnerability of the children and adolescents involved in the event. The psychological well-being of individual children is influenced by the following: 1) the type and intensity of exposure to the event, 2) the availability of family and community support during the event and during recovery, 3) the degree of dayto-day life disruption, and 4) the amount of social disorganization and chaos and the extent to which community social cohesion is maintained. In addition, vulnerability depends on individual characteristics of the child, the social and economic circumstances of the family and community, and the available resources in the surrounding environment and community. On the other hand, adolescents may be more self-sufficient and react in a manner somewhat independent from their caregivers. The adaptive capacity of nearly all children is influenced by the physical and emotional availability of their caregivers, but this is especially true for younger children. They may experience intense feelings of abandonment when separated from adults in the family who have been injured, dislocated, killed, or who are doing community work work and thus not available in ways they would normally be.
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Osman Y hypertension 6 months pregnant best 0.25 mg digoxin, Wadie B blood pressure chart lower number purchase digoxin us, El-Diasty T et al: High-energy transurethral microwave thermotherapy: symptomatic vs urodynamic success digital blood pressure monitor proven 0.25mg digoxin. Miller P, Kastner C, Ramsey E et al: Cooled thermotherapy for the treatment of benign prostatic hyperplasia: durability of results obtained with the Targis System. Bock D, Price D, Fay R: Prolieve transurethral microwave thermodilation versus finasteride: results of a multicenter, randomized trial in symptomatic patients with benign prostatic hyperplasia. Bach T, Herrmann T, Ganzer R et al: RevoLix vaporesection of the prostate: initial results of 54 patients with a 1-year follow-up. Hettiarachchi J, Samadi A, Konno S et al: Holmium laser enucleation for large (greater than 100 mL) prostate glands. Tan A, Gilling P, Kennett K et al: A randomized trial comparing holmium laser enucleation of the prostate with transurethral resection of the prostate for the treatment of bladder outlet obstruction secondary to benign prostatic hyperplasia in large glands (40 to 200 grams). Montorsi F, Naspro R, Salonia A et al: Holmium laser enucleation versus transurethral resection of the prostate: results from a 2-center, prospective, randomized trial in patients with obstructive benign prostatic hyperplasia. Briganti A, Naspro R, Gallina A et al: Impact on sexual function of holmium laser enucleation versus transurethral resection of the prostate: results of a prospective, 2-center, randomized trial. Kuntz R, Ahyai S, Lehrich K et al: Transurethral holmium laser enucleation of the prostate versus transurethral electrocautery resection of the prostate: a randomized prospective trial in 200 patients. Aho T, Gilling P, Kennett K et al: Holmium laser bladder neck incision versus holmium enucleation of the prostate as outpatient procedures for prostates less than 40 grams: a randomized trial. Monoski M, Gonzalez R, Sandhu J et al: Urodynamic predictors of outcomes with photoselective laser vaporization prostatectomy in patients with benign prostatic hyperplasia and preoperative retention. The A, Malloy T, Stein B et al: Impact of prostate-specific antigen level and prostate volume as predictors of efficacy in photoselective vaporization prostatectomy: analysis and results of an ongoing prospective multicentre study at 3 years. Neill M, Gilling P, Kennett K et al: Randomized trial comparing holmium laser enucleation of prostate with plasmakinetic enucleation of prostate for treatment of benign prostatic hyperplasia. Elzayat E, Habib E, Elhilali M: Holmium laser enucleation of prostate for patients in urinary retention. Tan A, Gilling P, Kennett K et al: Long-term results of high-power holmium laser vaporization (ablation) of the prostate. Kuntz R, Lehrich K, Ahyai S: Does perioperative outcome of transurethral holmium laser enucleation of the prostate depend on prostate size? Sandhu J, Ng C, Vanderbrink B et al: High-power potassium-titanyl-phosphate photoselective laser vaporization of prostate for treatment of benign prostatic hyperplasia in men with large prostates. Volkan T, Ihsan T, Yilmaz O et al: Short term outcomes of high power (80 W) potassium-titanylphosphate laser vaporization of the prostate. The A, Malloy T, Stein B et al: Photoselective vaporization of the prostate for the treatment of benign prostatic hyperplasia: 12-month results from the first United States multicenter prospective trial. Yuan J, Wang H, Wu G et al: High-power (80 W) potassium titanyl phosphate laser prostatectomy in 128 high-risk patients. Reich O, Bachmann A, Siebels M et al: High power (80 W) potassium-titanyl-phosphate laser vaporization of the prostate in 66 high risk patients. Bachmann A, Ruszat R, Wyler S et al: Photoselective vaporization of the prostate: the basel experience after 108 procedures. Fu W, Hong B, Wang X et al: Evaluation of greenlight photoselective vaporization of the prostate for the treatment of high-risk patients with benign prostatic hyperplasia. Kuo R, Paterson R, Siqueira T, Jr et al: Holmium laser enucleation of the prostate: morbidity in a series of 206 patients. Seki N, Mochida O, Kinukawa N et al: Holmium laser enucleation for prostatic adenoma: analysis of learning curve over the course of 70 consecutive cases. Chilton C, Mundy I, Wiseman O: Results of holmium laser resection of the prostate for benign prostatic hyperplasia. Salonia A, Suardi N, Naspro R et al: Holmium laser enucleation versus open prostatectomy for benign prostatic hyperplasia: an inpatient cost analysis. Gilling P, Mackey M, Cresswell M et al: Holmium laser versus transurethral resection of the prostate: a randomized prospective trial with 1-year followup. Montorsi F, Corbin J, Phillips S: Review of phosphodiesterases in the urogenital system: new directions for therapeutic intervention. Larner T, Agarwal D, Costello A: Day-case holmium laser enucleation of the prostate for gland volumes of < 60 mL: early experience. Tkocz M, Prajsner A: Comparison of long-term results of transurethral incision of the prostate with transurethral resection of the prostate, in patients with benign prostatic hypertrophy. Ekengren J, Haendler L, Hahn R: Clinical outcome 1 year after transurethral vaporization and resection of the prostate. Erdagi U, Akman R, Sargin S et al: Transurethral electrovaporization of the prostate versus transurethral resection of the prostate: a prospective randomized study. Ferretti S, Azzolini N, Barbieri A et al: Randomized comparison of loops for transurethral resection of the prostate: preliminary results. Fowler C, McAllister W, Plail R et al: Randomised evaluation of alternative electrosurgical modalities to treat bladder outflow obstruction in men with benign prostatic hyperplasia. McAllister W, Karim O, Plail R et al: Transurethral electrovaporization of the prostate: is it any better than conventional transurethral resection of the prostate? Gupta N, Doddamani D, Aron M et al: Vapor resection: a good alternative to standard loop resection in the management of prostates >40 cc. Hammadeh M, Madaan S, Singh M et al: A 3-year follow-up of a prospective randomized trial comparing transurethral electrovaporization of the prostate with standard transurethral prostatectomy. Netto N, Jr, De Lima M et al: Is transurethral vaporization a remake of transurethral resection of the prostate? Nuhoglu B, Ayyildiz A, Fidan V et al: Transurethral electrovaporization of the prostate: is it any better than standard transurethral prostatectomy? Karaman M, Kaya C, Ozturk M et al: Comparison of transurethral vaporization using PlasmaKinetic energy and transurethral resection of prostate: 1-year follow-up. Tefekli A, Muslumanoglu A, Baykal M et al: A hybrid technique using bipolar energy in transurethral prostate surgery: a prospective, randomized comparison. Fung B, Li S, Yu C et al: Prospective randomized controlled trial comparing plasmakinetic vaporesection and conventional transurethral resection of the prostate. Akcayoz M, Kaygisiz O, Akdemir O et al: Comparison of transurethral resection and plasmakinetic transurethral resection applications with regard to fluid absorption amounts in benign prostate hyperplasia. Erturhan S, Erbagci A, Seckiner I et al: Plasmakinetic resection of the prostate versus standard transurethral resection of the prostate: a prospective randomized trial with 1-year follow-up. Iori F, Franco G, Leonardo C et al: Bipolar transurethral resection of prostate: clinical and urodynamic evaluation. Patankar S, Jamkar A, Dobhada S et al: PlasmaKinetic Superpulse transurethral resection versus conventional transurethral resection of prostate. Yang S, Lin W, Chang H et al: Gyrus plasmasect: is it better than monopolar transurethral resection of prostate? Michielsen D, Debacker T, De Boe V et al: Bipolar transurethral resection in saline-an alternative surgical treatment for bladder outlet obstruction? Singh H, Desai M, Shrivastav P et al: Bipolar versus monopolar transurethral resection of prostate: randomized controlled study.
- Some warts have smooth or flat surfaces.
- Sulfa drugs
- Blood loss
- Blood clots in the veins, called thrombophlebitis
- Change in vision or speech
- Regular use of aspirin, ibuprofen, naproxen, or other nonsteroidal anti-inflammatory drugs (NSAIDs). Taking aspirin or NSAIDs once in a while is safe for most people.
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Often there is interest in comparing results from different studies to pulse pressure vs stroke volume digoxin 0.25 mg line gain information on the modifying effects of factors that may differ among studies pulse pressure in aortic regurgitation buy cheap digoxin on-line. For example pulse pressure equivalent buy generic digoxin 0.25 mg, Chapter 10 ("Transport of Risks") discusses estimates from medical studies from the standpoint of comparing risks for cancer sites where baseline risks differ greatly for Japanese and Caucasian subjects. It must be acknowledged that data are inadequate to develop models that take account fully of the many factors that may influence risks. This is illustrated effectively in analyses by Preston and colleagues (2002a) of breast cancer incidence in eight cohorts, where it was not possible to find a common model that adequately described data from all eight cohorts. Since data are inadequate to indicate clearly the correct choices, all are sources of uncertainty. The committee has quantified the uncertainty from its choice regarding transport of risks from a Japanese population to a U. Additional sources of uncertainty which have not been quantified, are projection of risks over time, which is primarily important for persons exposed early in life, and estimating risks from lowenergy X-rays, which is of importance in estimating risks from diagnostic medical procedures (for a discussion of this subject, see Chapter 1, "Different Effectiveness of -rays and X-rays"). Shore and Xue also summarized data from studies involving adult exposure and confirmed the finding from Abomb survivors that risks are much lower (and possibly nonexistent) among persons exposed as adults. Preston and colleagues (2002a) also analyzed data from additional cohorts: the New York acute postpartum mastitis cohort (Shore and others 1986), the Swedish benign breast disease cohort (Mattsson and others 1993), and two Swedish skin hemangioma cohorts exposed in infancy (Lundell and Holm 1996). These cohorts all exhibited patterns that were not compatible with the models noted in the previous paragraph and adopted by the committee. The reader should consult Preston and colleagues (2002a) for details on the differences, but they include lower risks for the skin hemangioma cohorts (possibly due to the lower dose rates at which they were exposed) and different age at exposure and attained age patterns for the New York postpartum mastitis and Swedish benign breast disease cohorts (possibly due to the existence of breast disease in these cohorts). The reasons for these differences are not understood, but remind us that our understanding of radiation risks is incomplete and that models used to describe radiation risks are likely to be oversimplifications. Site-Specific Solid Cancers Other Than Breast and Thyroid Most medical exposure results in nonuniform doses to various organs of the body; thus, only site-specific estimates can be compared. As noted earlier, not all studies involving medical exposure have adequate dosimetry or sample sizes to obtain informative quantitative risk estimates. Furthermore, doses are often at a level where cell killing is likely to have reduced the risk per gray. Table 12-11 summarizes risk estimates for selected sites from six medically exposed cohorts where doses for individuals were estimated. The studies included are those of women treated for cervical cancer (Boice and others 1988), women treated for uterine bleeding with intrauterine radium capsules (Inskip and others 1990a) or X-irradiation (Darby and others 1994), ankylosing spondylitis patients (Weiss and others 1994), people treated for peptic ulcer (Carr and others 2002), and tuberculosis fluoroscopy patients (Howe 1995). The estimates from medical studies can be considered an average over the exposure and attained ages of the study cohorts; in all cases, exposure occurred in adulthood. The studies with mean organ doses exceeding 2 Gy (stomach cancer in ankylosing spondylitis patients and colon cancer in the U. Although the pooled analyses did not include all studies addressing thyroid cancer risks from external radiation exposure, it included those considered most informative by the authors, who reviewed published studies of thyroid cancer and external radiation. Specifically, the analyses included cohort studies with at least 1000 irradiated subjects who had individual estimates of radiation dose to the thyroid and case-control studies with at least 20 thyroid cancer cases and adequate dose information. Shore and Xue (1999) summarized data from several studies of thyroid cancer risks in persons exposed in childhood that were not included in the analyses by Ron and colleagues Copyright National Academy of Sciences. Other cancers in this cohort also exhibited a decline in risk with time since exposure, although there was still evidence of risk at a reduced level after 25 years. They found no evidence of heterogeneity in the magnitude of the decrease in relative risk with time since exposure. The most striking discrepancies are for stomach cancer in ankylosing spondylitis patients (Weiss and others 1994) and lung cancer in tuberculosis fluoroscopy patients (Howe 1995). Howe found no evidence of bias from several potential sources that were investigated in the fluoroscopy study and attributed this finding to the fractionated nature of the exposure. Nevertheless, modification of radiation-induced risk by the presence of lung disease (tuberculosis) in this cohort seems a reasonable and perhaps likely possibility. A total of 116 cancer site-specific estimates were derived, including estimates for cancers of the salivary glands, esophagus, stomach, colon, rectum, liver, pancreas, larynx, lung, bone, nonmelanoma skin cancer, female breast, uterus, and ovary. Dose fractionation and differences in baseline risks were noted as additional contributing factors. In addition to the overall level of risk, medical studies can potentially inform us regarding patterns of risk by sex, age at exposure, and time since exposure. However, many of the relevant studies (such as those included in Table 12-11) were primarily single-sex studies involving exposure in adulthood, thus providing little information on the modifying effects of these factors. Several studies have confirmed the persistence of excess risk 30 or more years after exposure. Little conducted additional analyses that took account of curvature in the dose-response, cell sterilization, and fractionation of dose. Within each type of leukemia, Little and colleagues found no indication that patterns varied among the three cohorts. This was done both to yield more stable risk estimates and because updated leukemia incidence data (which would allow distinctions by subtype) were not available. Comparison with Studies of Nuclear Workers Exposed at Low Doses and Low Dose Rates As discussed in Chapter 8, the most promising studies for direct assessment of risk at low doses and low dose rates are those of nuclear workers who have been monitored for radiation exposure through the use of personal dosimeters. This made it possible to give much more detailed attention to cancer incidence (including nonfatal cancers) than in past evaluations. It also made it possible to develop more reliable estimates for site-specific cancers due to the higher-quality diagnostic information compared with that based on death certificates. The cancer incidence data analyzed by the committee included nearly 13,000 cases occurring in the period 19581998. The longer follow-up period and larger number of cancer deaths and cases allowed more precise evaluation of risk and also more reliable assessment of the long-term effects of radiation exposure. For other cancer sites, data suitable for quantitative risk assessment were limited; for example, medical exposures often involve large therapeutic doses. Two of the most important sources of uncertainty are (1) the possible reduction in risk for exposure at low doses and low dose rates. For cancer sites other than breast and thyroid (where data on Caucasian subjects are available), the committee presents estimates based on the assumption that the excess risk due to radiation is proportional to baseline risks (relative risk transport) and also presents estimates based on the assumption that the excess risk is inde- Copyright National Academy of Sciences. As a central estimate, the committee recommends a weighted estimate of these two results with the ratio of the two used to reflect the uncertainty in transporting risks. The committee provides estimates of lifetime risks of both cancer incidence and mortality for leukemia, all solid cancers, and cancers of several specific sites (stomach, colon, liver, lung, female breast, prostate, uterus, ovary, bladder, and all other solid cancers). As an example, Table 12-13 shows the estimated number of incident cancer cases and deaths that would be expected to result if a population of 100,000 persons with an age distribution similar to that of the entire U. The estimates are accompanied by 95% subjective confidence intervals that reflect the most important sources of uncertainty, namely, statistical variation, uncertainty in the factor used to adjust risk estimates for exposure at low doses and low dose rates, and uncertainty in the method of transport. Consideration of additional sources of uncertainty would increase the width of these intervals. For many cancer sites, uncertainty is very large, with subjective 95% confidence intervals covering greater than an order of magnitude. All details of these models are not given, but the general approaches that have been used are described. Separate models were developed for mortality from leukemia, breast cancer, respiratory cancer, digestive cancer, and all other cancers. The model for breast cancer mortality was based on both A-bomb survivor data and Canadian fluoroscopy patients.
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The center will develop field surveys arteria carotis discount digoxin 0.25 mg otc, share knowledge in the area of crime statistics pulse pressure under 40 discount digoxin 0.25mg visa, and organize an annual international conference on statistics blood pressure chart dogs order 0.25mg digoxin with amex. Fedotov stated: As criminal gangs and drug trafficking rings become more sophisticated in their quest to avoid detection and escape justice, we support the Mexican Government in strengthening and sharing data collection methods relating to governance, victims of crime, public security and justice so that it-and other countries-can better respond to these threats. The Executive Director also noted: We must all remember that organized crime has become transnational and borderless; it is no longer a problem of just one country. The Hemispheric Plan of Action put forth specific actions in the following areas: national strategies against transnational organized crime, legal instruments, law enforcement matters, training, information-sharing, and international cooperation and assistance. It focuses on strengthening the human and institutional capabilities and channeling the collective efforts of its member states to reduce the production, trafficking, and use of illegal drugs. These recommendations for action include establishing and/or refining laws and regulations to control weapons, ammunition, and related material to stem the growing violence posed by illegal drugs and crime. Its 52 articles cover five aspects: Institutional Strengthening, Demand Reduction, Supply Reduction, Control Measures, and International Cooperation. The latter program is devoted to promoting international cooperation and coordination with other international, regional, and subregional bodies, as well as the private sector. Several countries in the region have limited resources to confront drug-trafficking organizations that are often better trained and equipped than government forces. The situation is further complicated by the problematic history of those Latin American countries that have transitioned from military dictatorships to democratic governments responsible for safeguarding the rule of law. There remain deep-seated suspicions of the role of defense and security forces, and trepidation concerning abuses of 255 Realuyo power and corruption by these forces if they are employed against illicit networks. On the Development Front Central America has become the unfortunate victim of the aggressive counternarcotics campaigns of the governments of Colombia and Mexico. As illicit actors have perceived more risks in operating in Colombia and Mexico, they have stepped up their activities in Central America. Violence is particularly intense in the "northern triangle" countries of El Salvador, Guatemala, and Honduras, which have some of the highest homicide rates in the world. Citizens of nearly every Central American nation now rank public insecurity as the top problem facing their countries. Given the transnational character of criminal organizations and their abilities to exploit ungoverned spaces, some analysts assert that insecurity in Central America poses a threat to the United States. Its Security Commission was created in 1995 to develop and carry out regional security efforts to combat illicit networks among other transnational threats. Assistant Secretary of State for Western Hemisphere Affairs Arturo Valenzuela, Guatemalan Deputy Minister of the Presidency Mauricio Boraschi, Canadian Assistant Deputy Minister for the Americas Jon Allen, and Nicaraguan National Police First Commissioner Aminta Granera. The four pillars of the regional security strategy are Prevention, Combating Crime, Rehabilitation and Reintegration, and Institutional Strengthening. This strategy is based on the premise that security in Central America is a shared responsibility, and one of the key principles is that it implies an interconnected chain between local, national, and regional actions from a perspective of resource allocations and should take advantage of synergies, according to Aleman. The United States recognizes that its efforts in Colombia and Mexico have provided incentives for criminal groups to move into Central America and other areas where they can exploit institutional weaknesses to continue their operations. In response, the Obama administration has made ensuring the safety and security of all citizens one of the four overarching priorities of U. Among other activities, they conduct complex investigations into money laundering, bulk cash smuggling, and the trafficking of narcotics, firearms, and persons. They are aimed at addressing the complex threats posed by illicit networks by working with different segments of the society. Perhaps one of the greatest challenges for this important mission in Central America is U. Many experts on Central America are concerned that this will be insufficient to help Central American nations to realize rule of law, prosperity, and democracy in the face of the formidable illicit networks operating in the region. Not only do 258 Collaborating to Combat Illicit Networks Central American countries lack financial resources; they also require human resources and capacity to implement these security and development programs. On the Defense and Security Front In the Western Hemisphere, narcotics trafficking and its associated violence represent the gravest threat from illicit networks and pose a formidable challenge for government, defense, and security forces. For decades, Washington has invested significant resources in both the demand and supply side of counternarcotics efforts known as the "war on drugs. Secretary of State George Schultz, Virgin Group Founder Richard Branson, and Greek Prime Minister George Papandreou declared that the global war on drugs has failed after 40 years. It is responsible for providing contingency planning, operations, and security cooperation for Central and South America, the Caribbean (except U. It is also responsible for ensuring the defense of the Panama Canal and canal area. The Department of Defense is the lead Federal agency in efforts to detect and monitor aerial and maritime transit of illegal drugs toward the United States. It is responsible for the detection and monitoring of suspect air and maritime drug activity in the Caribbean Sea, Gulf of Mexico, and the eastern Pacific. The actual interdictions- boarding, search, seizures, and arrests-are led and conducted by embarked U. Coast Guard Law Enforcement Detachments or partner nation drug law enforcement agencies. Coast Guard, and partner nation (British, French, Dutch, Canadian, and Colombian) ships patrol the waters in the Caribbean Sea, Gulf of Mexico, and the eastern Pacific on a year-round basis. The mission and team had sufficient legitimacy with a clear mandate from senior civilian and military authorities. The mission was discrete and clearly identified (stop drug trafficking from entering the United States) with measurable outcomes (that is, number of arrests, interdictions, vessels boarded, and drug confiscations). A better understanding of partners, their interests, capabilities, and limitations fostered true collaboration and cooperation and unity of effort. It is a team that blends experience, professionalism, and knowledge that is greater than the sum of its individual parts, according to Admiral Stavridis. However, it is not apparent how easily this model with over 20 years of experience can be replicated in terms of human and financial resources as well as collaborative culture. Fostering Collaborative Models to Combat Illicit Networks Illicit networks that include criminals, terrorists, and facilitators have brokered strategic alliances to promote their interests, threatening the rule of law, global supply chains, and free and fair markets around the world. To counter the convergence of these threats, governments need to develop interagency and international strategies that leverage the diplomatic, development, intelligence, military, and law enforcement instruments of national power. To this end, collaborative models for security and development require the following critical elements: political will, institutions, mechanisms to assess threats and deliver countermeasures, resources, and measures of effectiveness to ensure success against illicit networks. All of the international and interagency initiatives examined in this chapter demonstrate the political will to combat illicit networks. In 2000, the United Nations formally recognized 262 Collaborating to Combat Illicit Networks Figure 4. To Combat Illicit Networks Foster Collaboration and Communities of Interest at the National, Regional, and International Levels Facilitators Intelligence Terrorists Criminals Military Law Enforcement Figure 5.
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Simple case definition of clinical benign prostatic hyperplasia blood pressure 9070 cheap 0.25mg digoxin with visa, based on International Prostate Symptom Score arrhythmia questions order digoxin master card, predicts general practitioner consultation rates pulse pressure variation critical care order 0.25mg digoxin with mastercard. Analysis of the inflammatory network in benign prostate hyperplasia and prostate cancer. Expression of protein kinase C isoenzymes in benign hyperplasia and carcinoma of prostate. Intra- and inter-investigator variation in the analysis of pressure-flow studies in men with lower urinary tract symptoms. Nocturnal polyuria in patients with lower urinary tract symptoms and response to alpha-blocker therapy. Effect of chronic prostatitis on angiogenic activity and serum prostate specific antigen level in benign prostatic hyperplasia. Is reduced quality of life in men with lower urinary tract symptoms due to concomitant diseases. Hirudin as anticoagulant for cardiopulmonary bypass: importance of preoperative renal function. Urinary N-acetyl-beta-D-glucosaminidase and neopterin aid in the diagnosis of rejection and acute tubular necrosis in initially nonfunctioning kidney grafts. Claudin-1 immunohistochemistry for distinguishing malignant from benign epithelial lesions of prostate. Response to sublethal heat treatment of prostatic tumor cells and of prostatic tumor infiltrating T-cells. Increased expression of lymphocyte-derived cytokines in benign hyperplastic prostate tissue, identification of the producing cell types, and effect of differentially expressed cytokines on stromal cell proliferation. Interstitial laser coagulation in benign prostatic hyperplasia: A critical evaluation after 2 years of follow-Up. Classification, epidemiology and implications of chronic prostatitis in North America, Europe and Asia. Detecting urethral and prostatic inflammation in patients with chronic prostatitis. Inconsistent localization of gram-positive bacteria to prostate-specific specimens from patients with chronic prostatitis. Inhibition of prostate cancer growth by vitamin D: Regulation of target gene expression. Redo ureteroneocystostomy using an extravesical approach in pediatric renal transplant patients with reflux: a retrospective analysis and description of technique. Race/ethnicity, obesity, health related behaviors and the risk of symptomatic benign prostatic hyperplasia: results from the prostate cancer prevention trial. Soft-copy versus hard-copy interpretation of voiding cystourethrography in neonates, infants, and children. Interleukin-8 secretion of cortical tubular epithelial cells is directed to the basolateral environment and is not enhanced by apical exposure to Escherichia coli. Prospective comparative study between data from questionnaire and frequency-volume charts. Voiding diary for the evaluation of urinary incontinence and lower urinary tract symptoms: prospective assessment of patient compliance and burden. Nocturia in patients with lower urinary tract symptoms: association with diurnal voiding patterns. Comparison of voiding parameters in men and women with lower urinary tract symptoms. Chronic prostatitis in Korea: a nationwide postal survey of practicing urologists in 2004. Significance of nocturnal hesitancy in treatment of men with lower urinary tract symptoms. Assessment of a fragment of e-cadherin as a serum biomarker with predictive value for prostate cancer. Usefulness of Gram stain for diagnosis of lower respiratory tract infection or urinary tract infection and as an aid in guiding treatment. Trends in the development of new drugs for treatment of benign prostatic hyperplasia. Re: histological changes of minimally invasive procedures for the treatment of benign prostatic hyperplasia and prostate cancer: clinical implications. Proton magnetic resonance spectroscopy with a body coil in the diagnosis of carcinoma prostate. Photoselective vaporization of the prostate: a volume reduction analysis in patients with lower urinary tract symptoms secondary to benign prostatic hyperplasia and carcinoma of the prostate. A prospective study of conservatively managed acute urinary retention: prostate size matters. The benefits of radical prostatectomy beyond cancer control in symptomatic men with prostate cancer. Diagnostic usefulness of monoclonal antibody P504S in the workup of atypical prostatic glandular proliferations. Transurethral holmium laser enucleation of the prostate versus transurethral electrocautery resection of the prostate: a randomized prospective trial in 200 patients. Transurethral holmium laser enucleation versus transvesical open enucleation for prostate adenoma greater than 100 gm. Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100 grams: 5-year follow-up results of a randomised clinical trial. Does perioperative outcome of transurethral holmium laser enucleation of the prostate depend on prostate size. The relationships of urethral and pelvic floor muscles and the urethral pressure measurements in women with stress urinary incontinence. Analysis of the pathophysiology of lower urinary tract symptoms in patients after prostatectomy. Botulinum A toxin urethral injection for the treatment of lower urinary tract dysfunction. Clinical effects of suburothelial injection of botulinum A toxin on patients with nonneurogenic detrusor overactivity refractory to anticholinergics. Clinical prostate score for diagnosis of bladder outlet obstruction by prostate measurements and uroflowmetry. Pathophysiology of lower urinary tract symptoms in aged men without bladder outlet obstruction. Prostate botulinum A toxin injection-an alternative treatment for benign prostatic obstruction in poor surgical candidates. Therapeutic effects of suburothelial injection of botulinum a toxin for neurogenic detrusor overactivity due to chronic cerebrovascular accident and spinal cord lesions. Page 126 114420 100120 109520 154500 106280 140500 140510 155740 107670 163850 136670 133040 128980 161480 139680 103450 127350 September 2010 Appendix 3: Master Bibliography American Urological Association, Inc. Investigation of dysfunctional voiding in children with urgency frequency syndrome and urinary incontinence. Therapeutic effect of multiple resiniferatoxin intravesical instillations in patients with refractory detrusor overactivity: a randomized, double-blind, placebo controlled study. Combined transurethal resection and vaporization of the prostate using newly designed electrode: a promising treatment alternative for benign prostatic hyperplasia.
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The upper ceiling of $200 billion was reached by doubling this number to blood pressure z score calculator generic digoxin 0.25mg on line account for statistical uncertainties heart attack protocol purchase digoxin discount. However blood pressure medication used for ptsd best order for digoxin, not a single customs organization in the world reports its interception rate, and it is likely that most have little idea what this interception rate might be. Therefore, statistically speaking, it is not clear how an average interception rate of counterfeit goods could be computed. Nevertheless, combining this detection rate with the approximately $2 trillion in imports for the United States, and assuming that counterfeit shipments have roughly the same international trade value as other shipments, the total international trade value of counterfeit goods going through U. Government estimates of economic losses resulting from counterfeiting could not be substantiated due to the absence of underlying studies and highlighted the difficulties of coming up with reliable estimates on the global extent and impact of counterfeiting. As early as 2002, a report for the European Commission had already established that "although many existing estimates of the size of the counterfeiting and piracy problems are based on extrapolating from the number of seizures, arrests or convictions made by enforcement agencies, we do not recommend this approach except in rare circumstances. This same report develops a detailed methodology to estimate counterfeiting for each of 19 different industries, including an estimate of the costs. The fundamental difficulty with estimating counterfeiting is that the brand owners are best positioned to know the significance and prevalence of the issue, or how to differentiate genuine articles from counterfeits. Generally speaking, however, the industry is unwilling to share the data it has collected, even though this is harming public health, consumers, and its own longterm interests. Industry associations, which have an interest in boasting large numbers, publicize estimates but often without any supporting methodology or access to underlying data. The difference between these two quantities corresponds to the commercial value of installed illicit software, which was valued at $59 billion for 2010. Interestingly, this technique of differentials is somewhat analogous to such methods as the World Bank Residual Model, which estimate illicit financial flows. The difficulty of performing direct observation is partly circumvented by measuring two quantities such as supply and demand that should in principle be equal in the absence of illicit activity. The difference between these two quantities corresponds to the amount of illicit activity. We could imagine using this principle to measure illicit activities for which it is hard or costly to make direct observation, but which can be measured as a difference between an input and an output. For example, counterfeiting could in some cases be measured as the difference between the legitimate supply and the total demand (which includes counterfeits) if the two quantities can be known or approximated, as is the case for the amount of deployed software. Excised Goods While the illicit trade in cigarettes is the most studied black market for the purpose of excise tax avoidance, it is likely that other illicit markets in excisable goods amount to tens of billions more. Illicit trade in tobacco creates a black market that is or can be relatively accurately 44 Global Scale and Impact of Illicit Trade measured. Defining the problem is relatively straightforward: illicit tobacco is traded for the primary purpose of avoiding excise taxes, either by smuggling tobacco from low to high taxation states or countries, by counterfeiting, or by local tax evasion. Identifying illicit tobacco is generally easier than other industrial goods because there is usually a tax stamp, which in the case of fraud is either absent, counterfeit, or does not match its intended destination. Furthermore, many cigarette companies have implemented forensic or digital means to identify fraudulent packs. Unlike many illicit markets, there is little ambiguity in measurement as well: the direct cost is the amount of unpaid taxes to countries. For sampling, the tobacco industry has developed detailed methodologies for avoiding biases when sampling the market. After having been extensively involved and complicit in the illicit trade because "smuggled cigarettes have helped the companies expand sales, make inroads in markets they cannot enter legally, increase their market share in competition with rivals, keep cigarette prices down generally or win legal import status or production in another country," tobacco companies now recognize illicit traders as an important competitor. Therefore, it is vital for them to understand the size, nature, and dynamics of the illicit segment. Having reliable metrics on illicit tobacco is seen as important for resource allocation purposes and for dialogue with the government. In many ways, this industry, despite being still perceived as backward-minded and uncooperative, is leading the way for other industries that are still somewhat reluctant to address their problems with illicit trade. However, accounting for the fact that a number of smokers of illicit cigarettes would quit if they had to pay the full price of excise taxes, governments could recover up to $31 billion. Human Trafficking Various estimates have been produced on the global scale of human trafficking. The report describes the methodologies, key assumptions, and limitations used by the U. Government estimates that 600,000 to 800,000 persons are trafficked across international borders annually. Forced labor is peculiar among illicit activities in that it extends over a long period, which allows for models that can be used to estimate the probability that events are reported over time. Therefore, it is theoretically possible to exhaustively review available sources, although this is not practical given the millions of publications that would need review. Capture-recapture methods are commonly employed in ecology to estimate population size when it is not possible to count all individuals present in the population, in which case an estimate of the total population can be inferred from the degree of overlap between different counts (the lower the overlap, the larger the estimate). Adapting this method, two separate teams searched for cases in a variety of databases for a period of 6 months and the estimate was extrapolated from the degree of overlap. Nevertheless, the transparency of assumptions, the effort to use a clear definition, and the overall availability of data sources provide a certain degree of confidence in this figure. The estimated annual profits are broken down by region of the world, and for sexual versus other commercial exploitation. The estimated total stands at $32 billion and represents an average revenue of $12,800 per person. Below we review the estimates on the global extent of illicit trade for each category. Illegal logging can be defined broadly to include violations of any number of international, national, or local laws and regulations. However, as pointed out in a report prepared for the American Forest & Paper Association,29 if illegal logging clearly signifies legal abuses, there is considerable debate about what might be considered illegal. A 2004 report from the World Bank on forest sustainability placed the annual revenue loss to governments from failure to collect taxes from forest concessions at more than $5 billion, and the annual market value of losses from illegal cutting of forests at over $10 billion. However, the American Forest & Paper Association reports that the World Bank estimate was published without reference to a supporting methodology, adding that "No matter how broad or narrow illegal forest activity might be interpreted, its extent is impossible to know with any degree of certainty. Reported estimates are generally supported only through 46 Global Scale and Impact of Illicit Trade anecdotal information and supposition. A 2009 study was apparently the first attempt to undertake a worldwide analysis of illegal and unreported fishing. The study uses primary data sources from several key composite studies supplemented by country-specific studies. In the source studies, a number of different methods have been used to estimate the level of illegal fishing, including surveillance data, trade data, stock assessments based on survey data, and expert opinion. The frequently cited global estimates ranging from $5 to $20 billion have no scientific basis. It nevertheless "highlights the lack of data on the scale and breadth of illegal waste movements. Government in 2000 estimated that criminal organizations earn $10 to $12 billion per year for dumping trash and hazardous waste materials. The convention covers offenses with a transnational component as well as so-called serious crimes such as money laundering and corruption, which "are made in order obtain, directly or indirectly, a financial or other material benefit. Whether international ramifications are found does not necessarily affect the dynamics of the market or the motivations of its actors.
One colleague remembers his unforgettable first impression of Freireich: "a giant prehypertension mayo clinic purchase digoxin 0.25mg free shipping, in the back of the room blood pressure medication usa discount digoxin 0.25 mg with visa, yelling and screaming on the phone arrhythmia heart beats cheap 0.25 mg digoxin free shipping. One of his former coworkers remembers Freireich coming across a routine error made by one of his medical residents. Jay screamed at him right there in the ward, in front of five or six doctors and nurses. We can take that route because we have been supported and comforted and understood in our suffering. That support gives us a model of how to feel for others: it is the basis for empathy. Once, in the middle of reminiscing about his career, Freireich burst into an attack on the idea that terminally ill cancer patients be given hospice care at the end of their lives. On Tuesday morning, I make teaching rounds, and sometimes the medical fellows say, `This patient is eighty years old. But we also want a physician who can stand in our shoes and understand what we are feeling. We want to be treated with dignity, and treating people with dignity requires empathy. In the early 1960s, a psychologist named Marvin Eisenstadt started a project interviewing "creatives"-innovators and artists and entrepreneurs-looking for patterns and trends. The group he was studying was so small that Eisenstadt knew there was a possibility that what he was seeing was just chance. In the 1950s, while studying a sample of famous biologists, the science historian Anne Roe had remarked in passing on how many had at least one parent who died while they were young. The same observation was made a few years later in an informal survey of famous poets and writers like Keats, Wordsworth, Coleridge, Swift, Edward Gibbon, and Thackeray. More than half, it turned out, had lost a father or mother before the age of fifteen. The link between career achievement and childhood bereavement was one of those stray facts that no one knew what to do with. He then began systematically tracking down biographical information for everyone on the list. I tracked down as many parental-loss profiles as I could, until I felt I had good statistical results. Even for the years before the twentieth century, when life expectancy due to illness and accidents and warfare was much lower than it is today, those are astonishing numbers. Her focus was on the period from the beginning of the nineteenth century to the start of the Second World War. What sort of backgrounds and qualities, she wondered, predicted the kind of person capable of rising to the top of British politics at a time when it was the most powerful country in the world? Like Eisenstadt, however, she got sidetracked by a fact that, as she wrote, "occurred so frequently that I began to wonder whether it was not of more than passing significance. There is a fascinating passage in an essay by the psychologist Dean Simonton, for example, in which he tries to understand why so many gifted children fail to live up to their early promise. One of the reasons, he concludes, is that they have "inherited an excessive amount of psychological health. In contrast, geniuses have a perverse tendency of growing up in more adverse conditions. Losing a father or a mother is the most devastating thing that can happen to a child. The psychiatrist Felix Brown has found that prisoners are somewhere between two and three times more likely to have lost a parent in childhood than is the population as a whole. There are, clearly, an enormous number of direct hits from the absence of a parent. Your father can commit suicide and you can suffer from a childhood so unspeakable that you push it to the furthest corners of your memory- and still some good can end up coming from that. When Jay Freireich arrived at the National Cancer Institute in 1955, he reported to Gordon Zubrod, the head of cancer treatment. Zubrod came around once a week to see how we were doing," Freireich remembered, "and he said to me, `Freireich, this place is like an abattoir! The nurses would come to work in the morning in their white uniforms and go home covered in blood. But the problem was that controlling the bleeding was so difficult that most of the children were dead before anyone could figure out how to help them. Or you get an infection and then you get pneumonia, then you get fever, and then you get convulsions, and then. Together, they became convinced that the problem was a lack of platelets-the irregularly shaped cell fragments that float around in human blood. He used a more sophisticated methodology and zeroed in on subtle changes in the platelets at really low levels, and to him the connection was clear: the lower the platelet count, the worse the bleeding. The father of one of his patients was a minister, and he brought in twenty members of his congregation. Standard procedure in blood transfusions in the mid-1950s was steel needles, rubber tubes, and glass bottles. So Freireich had the idea of switching to the brand-new technology of silicon needles and plastic bags. Take a look again at what MacCurdy wrote about the experience of being in the London Blitz: We are all of us not merely liable to fear, we are also prone to be afraid of being afraid, and the conquering of fear produces exhilaration. When we have been afraid that we may panic in an air-raid, and, when it has happened, we have exhibited to others nothing but a calm exterior and we are now safe, the contrast between the previous apprehension and the present relief and feeling of security promotes a self-confidence that is the very father and mother of courage. Let us start with the first line: We are all of us not merely liable to fear, we are also prone to be afraid of being afraid. Because no one in England had been bombed before, Londoners assumed the experience would be terrifying. What frightened them was their prediction about how they would feel once the bombing started. And: the contrast between the previous apprehension and the present relief and feeling of security promotes a self-confidence that is the very father and mother of courage. Courage is not something that you already have that makes you brave when the tough times start. They bombed London because they thought that the trauma associated with the Blitz would destroy the courage of the British people. It created a city of remote misses, who were more courageous than they had ever been before. The next chapter of David and Goliath is about the American civil rights movement, when Martin Luther King Jr. There is one part of the Birmingham story that is worth touching on now, though, because it is a perfect example of this idea of acquired courage.