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In terms of race/ethnicity, describing issues and situations that arise within the pop six of the task force members identied as White and four ulation. Gender identity is dened as a per ject matter experts within and outside of psychology. When sons deeply felt, inherent sense of being a girl, woman, or the Task Force discovered a lack of professional consensus, female; a boy, a man, or male; a blend of male or female; every effort was made to include divergent opinions in the or an alternative gender (Bethea & McCollum, 2013; In eld relevant to that issue. In many cultures and Force described the various approaches documented in the religious traditions, gender has been perceived as a binary literature. Additionally, these Guidelines were informed by construct, with mutually exclusive categories of male or comments received at multiple presentations held at pro female, boy or girl, man or woman (Benjamin, 1966; fessional conferences and comments obtained through two Mollenkott, 2001; Tanis, 2003). These mutually exclusive cycles of open public comment on earlier Guideline drafts. There is historical evidence of recognition, and (e) research, education, and training. Many cultures in which modify their understanding of gender, broadening the range gender nonconforming persons and groups were visible of variation viewed as healthy and normative. By under were diminished by westernization, colonialism, and sys standing the spectrum of gender identities and gender ex temic inequity (Nanda, 1999). Re cation about the healthy variation of gender identity and search over the last two decades has demonstrated the gender expression, and the incorrect assumption that gen existence of a wide spectrum of gender identity and gender der identity automatically aligns with sex assigned at birth. How people and provide a safe environment to explore gender ever, people may experience distress associated with dis identity and make informed decisions about gender expres cordance between their gender identity and their body or sion. Psychologists understand that Between the late 1960s and the early 1990s, health gender identity and sexual orientation are care to alleviate gender dysphoria largely reinforced a distinct but interrelated constructs. Devor, surgery or hormone therapy because medical and mental 2004; Drescher & Byne, 2013). Sexual orientation is de health care provider endorsement was required before sur ned as a persons sexual and/or emotional attraction to gery or hormones could be accessed (Berger et al. For most people, gender identity research and models of trans-affirmative care, there is develops earlier than sexual orientation. Although gender iden salient, better integrated, or increasingly egosyntonic tity is usually established in childhood, individuals may (Bockting et al. The developmental pathway of gender orientation that previously had been repressed, hidden, or identity typically includes a progression through multiple in conict with their identity. Devor, widened spectrum of attraction, or a shift in how they 2004; Vanderburgh, 2007). To explain any discordance they may developmental processes in exploring and affirming gender experience between their sex assigned at birth, related identity. It can be very important to include sexual orien derstand how gender identity and sexual orientation are tation and gender identity in the process of identity explo different but related; this may be particularly useful when ration as well as in the associated decisions about which working with youth (Singh & Burnes, 2009; Whitman, options will work best for any particular person. Psychologists may assist people in may have profound intersections with other aspects of differentiating gender identity and sexual orientation. Because of their roles in assessment, treatment, and others may create stigma and hinder empowerment (Burnes prevention, psychologists are in a unique position to help & Chen, 2012;K. Psychologists cultural biases, as Asian American/Pacic Islander trans woman may experi well as the cultural differences between psychologists and ence the benet of being perceived as a cisgender woman, their clients, have a clinical impact (Israel, Gorcheva, but may also experience sexism, misogyny, and objecti Burnes, & Walther, 2008; Vasquez, 2007). The assump cation particular to Asian American/Pacic Islander cis tions, biases, and attitudes psychologists hold regarding gender women. They may also develop perpetuate barriers to care (Bess & Stabb, 2009; Rachlin, resilience and strength in coping with disadvantages, or 2002). Improved rapport and medical care due to antitrans bias, and 19% were refused therapeutic alliance are likely to develop when psycholo care due to discrimination. Given how easily assumptions or stereotypes could to manage the intersection of stigmatized identities (Singh, inuence treatment, evidence-based practice may be espe 2012). Discrimination may also include refusing access to In an effort to develop competence in working with housing or employment or extreme acts of violence. This examination may include exploring ones own likely to receive help from law enforcement (Edelman, gender identity and gendered experiences related to privi 2011; National Coalition of Anti-Violence Programs, 2011; lege, power, or marginalization, as well as seeking consul Saffin, 2011). Psychologists recognize how tively impacted their careers or their well-being, such as stigma, prejudice, discrimination, and hiding who they were to avoid workplace repercussions violence affect the health and well-being of (Grant et al. Military regulations cite trans or making the assumption that psychopathology exists sexualism as a medical exclusion from service (Depart given a specic gender identity or gender expression (Na ment of Defense, 2011; Elders & Steinman, 2014).

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The role of alcohol expectancies and alcohol consumption among sexually victimized and nonvictimized college women. The incidence and prevalence of women abuse in Canadian University and college dating relationships. The role of family factors, physical abuse, and sexual victimization experiences in high risk youths alcohol and other drug use and delinquency: a longitudinal model. Reporting sexual victimization to the police and others: Results from a national-level study of college women. The generalized exponential model for sampling weight calibration for extreme values, non-response, and post-stratification. Dating aggression, sexual coercion, and aggression-supporting attitudes among college men as a function of participation in aggressive high school sports. Motives to drink as mediators between childhood sexual assault and alcohol problems in adult women. Situation-specific assertiveness in the epidemiology of sexual victimization among university women. Risk factors for sexual victimization in dating: A longitudinal study of college women. Rape-related Pregnancy: Estimates and Descriptive Characteristics from a National Sample of Women. Rape supportive attitudes and sexual victimization experiences of sorority and nonsorority women. A 2-year longitudinal analysis of the relationships between violent assault and substance use in women. The scope of rape: Incidence and prevalence of sexual aggression and victimization in a national sample of higher education students. Hidden rape: Sexual aggression and victimization in a national sample of students in higher education. Discriminant analysis of risk factors for sexual victimization among a national sample of college women. Male and female recipients of unwanted sexual contact in a college student sample: Prevalence rates, alcohol use, and depression symptoms. Recommendations for toxicological investigations of drug-facilitated sexual assaults. The contribution of alcohol to the likelihood of completion and severity of injury in rape incidents. Alcohol consumption, outcome expectancies, and victimization status among female college students. An exploratory analysis of suspected drug-facilitated sexual assault seen in a hospital emergency department. National Victim Center and Crime Victims Research and Treatment Center, University of South Carolina, Charleston. The role of womens alcohol consumption in evaluation of vulnerability to sexual aggression. Womens substance use and experiences of intimate partner violence: A longitudinal investigation among a community sample. The role of womens substance use in vulnerability to forcible and incapacitated rape. Full report of the prevalence, incidence, and consequences of intimate partner violence against women: Findings from the National Violence Against Women Survey. Report prepared for the National Institute of Justice and the Centers for Disease Control and Prevention. Adolescent Sexual Behavior, Drug Use, and Violence: Increased Reporting with Computer Survey Technology. Dating and sexual victimization: An analysis of risk factors among precollege women. Health and behavioral consequences of binge drinking at colleges: A national survey of students at 140 campuses. Interview Questions Used in Sexual Assault Classification this section of the interview asks about nonconsensual or unwanted sexual contact you may have experienced.

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An reported that their hearing aid was helpful in the alleviation of encouraging finding of the present study was the confirmation of tinnitus. The finding that 60% of individuals do not receive tinnitus relief from hearing aid use, however, highlights That is, approximately 40% of hearing aid users will receive the need for conducted research. Furthermore, relief will occur tinnitus evaluation results to the most effective treatments for an whether tinnitus is mild, moderate or severe. Schaette R, Kempter R (2009) Predicting tinnitus pitch from patients characteristics, causes, mechanisms, and treatments. J Clin Neurol audiograms with a computational model for the development of 5(1): 11-19. Diagnosis and treatment of phenomenon and its possible neural underpinnings in the dorsal this elusive symptom. Kleinjung T, Vielsmeier V, Landgrebe M, Hajak G, Langguth B (2008) Transcranial magnetic stimulation: a new diagnostic and therapeutic 17. Heber S, Carrier J (2007) Sleep complaints in elderly tinnitus patients: tool for tinnitus patients. Jastreboff P J (1990) Phantom auditory perception (tinnitus): mechanisms of generation and perception. Kleinjung T, Steffens T, Londero A, Langguth B (2007) Transcranial biofeedback treatment in tinnitus sufferers. Permission is granted to boards of nursing to use or reproduce all or parts of this document for licensure related purposes only. Nonproft education programs have permission to use or reproduce all or parts of this document for educational purposes only. Use or reproduction of this document for commercial or for-proft use is strictly prohibited. Any authorized reproduction of this document shall display the notice: Copyright by the National Council of State Boards of Nursing, Inc. It is used to guide candidates preparing for the examination, to direct item writers in the development of items, and to facilitate the classification of examination items. This document offers a comprehensive listing of content for each client needs category and subcategory outlined in the test plan. Sample items are provided at the end of each category, which are specific to the client needs category in that section. Nursing care activities are then analyzed in relation to the frequency of performance, impact on maintaining client safety, and client care settings where the activities are performed. This analysis guides the development of a framework for entry-level nursing practice that incorporates specific client needs as well as processes fundamental to the practice of nursing. It serves as a guide for examination development as well as candidate preparation. They are unique individuals who have defined systems of daily living reflecting their values, motives and lifestyles. People have the right to make decisions regarding their health care needs and to participate in meeting those needs. The profession of nursing makes a unique contribution in helping clients achieve an optimal level of health in a variety of settings. Nursing is both an art and a science, founded on a professional body of knowledge that integrates concepts from the liberal arts and the biological, physical, psychological and social sciences. It is a learned profession based on knowledge of the human condition across the life span and the relationships of an individual with others and within the environment. The goal of nursing for client care is preventing illness and potential complications; protecting, promoting, restoring, and facilitating comfort, health and dignity in dying. The nurse assists clients to promote health, cope with health problems, adapt to and/or recover from the effects of disease or injury, and support the right to a dignified death. Classification of Cognitive Levels Blooms taxonomy for the cognitive domain is used as a basis for writing and coding items for the examination (Bloom, et al. Since the practice of nursing requires application of knowledge, skills and abilities, the majority of items are written at the application or higher levels of cognitive ability, which requires more complex thought processing. Test Plan Structure the framework of Client Needs was selected for the examination because it provides a universal structure for defining entry-level nursing actions and competencies, and focuses on clients in all settings. In this collaborative environment, the nurse provides encouragement, hope, support and compassion to help achieve desired outcomes. Events and activities associated with client care are recorded in written and/or electronic records that demonstrate adherence to the standards of practice and accountability in the provision of care.

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In other What are some of the reasons that cases, women may leave a violent partner. However, many people remain in women remain in relationships in violent relationships. By fears 2 Much can be done to reduce the incidence of gender-based violence, such for ones safety Worries about community as ensuring that people know that they have the right to live free of violence, attitudes The conditions of human beings change, sometimes for the better and sometimes for the worse. Yet, they are also expected to become more respectful and caring in their relationships with women. They are also redefning masculinity in ways that allow boys and men to lead fuller lives as individuals, partners, fathers, and members of a just society. Challenging gender stereotypes requires honest and active thinking about our own experiences and 4 In order to reduce gender-based discrimination, people must be able to recognize attitudes. It may be obvious: for example, giving key leadership positions or other What sexual behavior do I think is acceptable for females Or it can be more subtle and difcult to notice: for example, ignoring How do I feel about girls having someones opinion because of her or his gender. They do this to help create greater happiness in their own relationships and lives, in their communities, and in the broader society. Gender: socially or culturally defned ideas about masculinity (male roles, attributes, and behaviors) and femininity (female roles, attributes, and behaviors). Gender equality/inequality: equal (or unequal) opportunities, burdens, and social, political, and economic power of males and females. Gender norms also refer to views on how strictly or consistently people should comply with one gender role or another. Gender roles: the social roles assigned to males or females by the society or family in which they live. Such roles include, for example, how they should behave or what jobs they should have. Patriarchy: a system of male domination across society, based on belief in the superiority of males. Sex: Sex is the diference in biological characteristics of males and females, determined by a persons genes. People experience sexuality through their physical feelings, emotions, thoughts, identity, and relationships. Cultural norms, individual experiences, and hormones all infuence the way we understand and experience sexuality. This unit helps young people understand what sexuality is and what factors afect the way we experience and understand sexuality. It helps young people to understand why sexual relationships require a level of maturity and to become more comfortable discussing sexual issues. It highlights the importance of consent, mutuality, and respect in sexual relationships. Address the positive aspects of sexuality, but keep in mind that many adolescents do not want to have intercourse, and many are simply not yet developmentally or socially ready to have sex. Be clear that a safe and comfortable sexual relationship requires a certain maturity and power to negotiate for oneself; emphasize especially the importance of mutuality and respect. Many young people feel ambivalent about what they want or confused about their partners wishes. You may wish to look for resources or support to help you refect on your areas of discomfort or confict regarding sexuality. Help your students understand and feel comfortable with the correct terms for body parts.

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Their most char overall pharmacokinetics for rufinamide are similar in children acteristic (and serious) seizure types are tonic and tonic/atonic and in adults, including the elderly, with clearance proportionate drop attacks, which cause sudden falls and injuries. Patients taking Seizures associated with falls (predominantly tonic and valproic acid, especially children, had increases in rufinamide tonic/atonic seizures) and total seizures were assessed. Seizure responder however, reduced dose reductions of 50% to 60% have been rates (proportions of patients with 50% seizure reduction) recommended for small children (30 kg) taking valproic acid were also significantly higher for patients treated with rufi (14). Efficacy was sustained during open-label extension treat Adolescents and adults receiving valproic acid had much small ment, with decreases in seizure frequency of 43% to 79% dur increases in rufinamide concentrations than children: 26% ing 6 to 36 months of treatment; patients converting from increases in adolescents and 16% increases in adults (14). Responder rates for patients, during their most decreases in rufinamide concentrations: carbamazepine (19% recent 6 months of therapy, were 45. Lamotrigine and topira were free of tonic/atonic seizures during their last 6 months of mate did not alter rufinamide concentrations (6). Although rufinamide treatment significantly increased patients time to having one, two, or 15 three seizures compared to placebo (P 0. A randomized, double-blind, placebo-controlled, adjunctive trial enrolled 269 pediatric patients between the ages of 4 to 15 years of age (23). Seizure frequencies for children treated Partial-Onset Seizure Trials with rufinamide (45 mg/kg/day) decreased by an average of only 7% compared to a 12. A number of children with very high seizure partial-onset seizures in adults in two large randomized, frequencies appeared to influence the assessment of seizure placebo-controlled, multicenter trials. In one large trial of adults (16 years, higher responder rates (50% reduction in seizures) (27. There were no Short-Term Therapy increased risks for sudden cardiac death or other cardiac abnormalities identified in clinical trials. Safety and tolerability were evaluated in patients receiving Pregnancy risks for women treated with rufinamide are rufinamide treatment (N 1240, with a mean age of unknown. The mean planned terminations, 1 had a spontaneous abortion, and 3 did dose of rufinamide was 1373 mg/day with a median daily dose not have pregnancy outcomes determined. Due to a lack of out were headache, dizziness, fatigue, somnolence, and nausea come data, women of childbearing age receiving rufinamide are (Table 64. Patients becoming pregnant will require individual assess ments of their risk benefits for continuing rufinamide therapy. Metabolism of the new anticonvulsant trial drug rufinamide 100 mg tablet is available in Europe. The influence of food on the disposition of the antiepileptic rufinamide in healthy volunteers. Rufinamide: pharmacology, treatment may begin treatment at one half of these doses. An early open treatment series, for example, dynamic parameters of adjunctive rufinamide in patients with Lennox showed that gradual rufinamide titration, with increases every Gastaut syndrome. Adjunctive rufinamide in Lennox seizures and encephalopathies (26), but who do not meet clini Gastaut syndrome: a long-term, open-label extension study.

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It is useful to have national-level data to monitor and assess policy impact and to revise and fne-tune policies based on such data. Womens rights groups in India, Mexico and Brazil, for example, have sometimes opposed using public funds to promote engaging men, or to fund paternity leave, for example, over the very real concerns that men will not use the time to provide child care or that funds for empowering women are already in short supply. Similarly, it is important to forge ties with other social justice movements that may be attuned to gender equality issues, including labor movements and civil society groups promoting rights for socially excluded groups. Norways experience also arms the need to frame gender equality and the inclusion of men in such policies as a public good with benefits for all. Fundamental to the success of changing policy to support gender equality is to frame the issues in ways that people fnd logical and compelling. Carrying out mass media campaigns and other eorts to educate the public and carry out public dialogues about gender equality policies, engaging men in the process, have also been important strategies in some contexts. Across all the countries, work to engage men in ending violence against women has been one of the low-hanging fruits in engaging men and boys to support gender equality. Brazil is the only country out of the fve where public (federal-level) funds are used for batterer intervention programs. Mexico has such programs but they are municipal-funded and available only in a few municipalities (Mexico City). Another example is the opportunity to discuss men in the rollout of antiretroviral therapy and male circumcision. Similarly, the rollout of male circumcision can, if so designed, provide an opportunity for discussing mens sexuality in ways that have previously been impossible. While there are numerous examples of excellent policy language related to men in all the countries included, eective and real implementation must be stimulated, enforced and monitored by civil society. Further, it is shortsighted to expect that policies by themselves achieve large-scale social change. At least some of the changes in gender roles and social norms related to gender in these and other countries have been inspired by womens rights organizations. Even when there have been backlashes (as in India in some states around sexuality education, and the culture wars in Mexico on the same themes), the debates around young people have often included the development of public interventions within a construct of gender specifcity: that is, acknowledging and calling attention to the specifc needs and realities of young women and/or young men. Countries of the European Union with gender policies, including Finland and Norway, often have commissions that are responsible for organizing discussions on engaging men. Simply creating such commissions does not, of course, mean that men and masculinities have been fully included in gender equality policies, but they have been important in generating public debate on the issue. Lingering Challenges e country case studies (and the other examples) arm not only the growing number of strategies for including men and masculinities within gender equality and social policies but also the lingering challenges. As our South African partners write, masculinities often become evident in law and policy when these instruments engage with the criminal, antisocial or destructive behaviors of men. Public policy is thus generally geared to limit, constrain or punish mens behavior. Much less often is policy framed as providing an opportunity to change constructions of masculinity in a positive way as part of a broader social project of building gender equity in society through constructive engagement with men and boys. Policies more often reinforce traditional, non equitable and violent versions of masculinities than confront them, and have been slow to question the traditional focus on men solely as providers. Policies tend to treat men and boys, for example, as providers but not caregivers. As one example, while all the countries included have some maternity leave, paternity leave continues to be minimal to nonexistent (fve days in Brazil and Chile, none in India, two weeks in South Africa). Similarly, income generation and unemployment support programs in nearly all the countries view women as caregivers and men as providers, with little policy work so far to support a notion of both men and women as caregivers and as providers, which is the reality of an increasing proportion of the worlds women and men. Policies are stuck refecting the traditional household division of labor: men as breadwinners and women as caregivers with negative implications for both. In an example from South Africa, rights and obligations have been extended for unmarried fathers, but parental leave remains the reserve of women. In India, women are not included in some rural development employment schemes, while men are not included in family leave. In other sectors, many services designed for women (health, childcare, child welfare) often exclude men, treating them as dangerous and reinforcing double and triple burdens on women. Conflicting policies may emerge from dierent ministries or departments with divergent perspectives.


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Primary Endorser: Cardiovascular Toxicology Specialty Section Other Endorser(s): Drug Discovery Toxicology Specialty Section; Regulatory and Safety Evaluation Specialty Section Echocardiography provides a noninvasive means to assess cardiac structure and function and is widely used clinically to assess left ventricular function, hypertrophy, valvular disease, and myocardial infarction. Increasingly, echocardiography has become a sought-after tool in nonclinical research to make informed decisions on intended pharmacology and/or off-target actions of test articles under development. The session will start with an outline of the use of small (rodents) and large (dogs, monkeys) animal echocardiography, including a description of common endpoints assessed. In addition, the first presenter will address the utility of echocardiography in healthy animals and animal models of cardiac disease as part of nonclinical safety assessment. The second presenta tion will address a range of anatomic, behavioral, and hemodynamic factors that affect quantitative analyses, including common design elements used to maximize data quality and effect size detection thresholds, and potential pitfalls to avoid. The target audience is toxicologists who may have limited exposure to the utility of echocardiography in nonclinical animal studies and are looking to expand their knowledge in the area. Based on the fact that cardiovascular liabilities continue to be a leading cause of drug attrition in late-stage clinical trials and post-market approval, it is expected that additional measures to assess cardiac function will be of great interest to the toxicology and drug development communities. Abstract # #2555 3:00 the Utility of Echocardiography in Cardiac Safety Assessment. Walisser #2558 3:55 Echocardiography in Nonclinical Safety Assessment: A Regulatory Perspective. Data will be presented from assays that assess genotoxicity, hepa totoxicity, and cardiotoxicity, along with an overview ofin vitrotoxicology panels. Attendees will gain insight into Eurofinss approach for screening drug candidates, which assesses drug safety profiles earlier in the discovery process, ultimately improving the likelihood of advancing safer molecules into clinical development. Many of these diseases are inherited or start in utero from naturally occurring mutations, so the key target population for therapy is young infants. How do we accelerate entry into these trials, before significant or irretrievable loss of abilities has occurred Presented by: Ellegaard Gottingen Minipigs A/S and Marshall BioResources In this session the reasons for selecting Gottingen Minipigs for preclinical studies will be reviewed. Primary Endorser: Postdoctoral Assembly Other Endorser(s): Ethical, Legal, Forensics, and Societal Issues Specialty Section; Graduate Student Leadership Committee For research to broadly and positively impact public health, it must be efficiently communicated to, and understood by, the general public. The majority of univer sity-level scientific training focuses on performing cutting-edge research and sharing those findings with other scientists within ones own field. In a time where information is readily accessible, ensuring effective and accurate scientific messaging through community outreach is necessary for maximizing societal impact and understanding. This is true during one-on-one conversations with nonscientists, and through interactions utilizing social and mass media. Deficiencies in the capacity to share science-related topics with nonscientists result in misinterpretation of conclusions and decreased community engagement in science. This session is designed to bring in scientific outreach experts to share tips and strategies for researchers to successfully communicate science with the general public. Speakers will focus on (1) individual interactions, (2) controlling your message, (3) the use of innovative social media platforms, and (4) effective utilization of mass media. These interactive presentations will include real-world examples of successful scientific communication as well as illustrations of common errors scientists are prone to committing. These discussions will be highly applicable to all attendees, including graduate students, postdoctoral trainees, and senior toxicologists. This session will allow both trainees and seasoned toxicologists to learn and implement this increasingly useful and necessary skill set. Abstract # #2559 4:45 Tips for Improving Scientific Communication with a General Audience. This is the eighth year of the Tox ShowDown, the toxicological quiz game par excellence. Topics run the gamut, including the role of toxicology in history, current events, arts, culture, and society, not to mention science.

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The acoustic component has been designed to provide stimulation to auditory pathways deprived by hearing Proprietary Tinnitus Treatments Medical Clinical Policy Bulletins | Aetna Page 30 of 89 loss, engage with the limbic system, and allow intermittent, momentary tinnitus perception within a pleasant and relaxing stimulus, thereby facilitating desensitization to the tinnitus signal. In the second, subjects experienced little tinnitus perception while listening to the treatment for the first 2 months, then experienced intermittent perception. Subjects were provided with a high-fidelity personal sound player with earphones and an acoustic stimulus that had been spectrally modified according to their individual audiometric profile. They were instructed to use the acoustic stimulus for at least 2 hours per day, particularly at those times when their tinnitus was usually disturbing. Each group had equal amounts of clinician time for education, monitoring, and support. At 2, 4, 6, and 12 months after commencing treatment, both groups displayed clinically and statistically significant improvements in tinnitus distress, awareness, and minimum masking levels as well as loudness discomfort levels. Improvements increased with time over the first 6 months of therapy, at which time 91 % of all subjects across the 2 groups reported an improvement in tinnitus disturbance (as measured by the Tinnitus Reaction Questionnaire) of at least 40 %, with a mean improvement of 65 %. Furthermore, 80 % of subjects at 6 months reported a level of tinnitus disturbance that was no longer clinically significant. There was some indication of a more consistent benefit over 12 months for the group that was provided initially with a high level of tinnitus interaction; Proprietary Tinnitus Treatments Medical Clinical Policy Bulletins | Aetna Page 31 of 89 however, inter-group differences were not statistically significant. A relation between reported treatment usage (hours per day) and clinical outcomes was observed, suggesting that a "dosage effect" may apply with the stimulus provided. This was a consistent effect, provided by a treatment that subjects reported as being pleasant to use. Both of the stage based variations of the treatment that were tested in this study were shown to be successful in achieving these outcomes. This treatment approach is provided as part of a structured rehabilitation program. By contrast, only 47 % and 23 % of the Noise + Counseling and Counseling-Only groups, respectively, reported a successful result according to this criterion. Proprietary Tinnitus Treatments Medical Clinical Policy Bulletins | Aetna Page 32 of 89 the major drawbacks of these two studies were (i) small numbers of subjects, and (ii) short-term follow-up (not exceeding 12 months). Moreover, it is unclear whether they were overlapping of patients in these two studies. Au ditory Perceptual Training Hoare et al (2010) stated that auditory perceptual training affects neural plasticity and so represents a potential strategy for tinnitus management. These investigators assessed the effects of auditory perceptual training on tinnitus perception and/or its intrusiveness via a systematic review of published literature. The 10 studies identified were reviewed independently by 2 reviewers, data were extracted, study quality was assessed according to a number of specific criteria and the information was synthesised using a narrative approach. Nine out of the 10 studies reported some significant change in either self-reported or psychoacoustic outcome measures after auditory training. However, all studies were quality rated as providing low or moderate levels of evidence for an effect. The authors identified a need for appropriately randomized and controlled studies that will generate high quality unbiased and generalisable evidence to ascertain if auditory perceptual training has a clinically relevant effect on tinnitus. In a randomized, prospective, single-blind study, Araujo and colleagues (2005) tested the effectiveness of intra-tympanic dexamethasone injections as a treatment for severe disabling cochlear tinnitus. A total of 36 patients with severe disabling tinnitus predominantly of cochlear origin were randomly assigned to receive intra-tympanic injections of a dexamethasone solution or isotonic saline solution. Five patients were excluded from analysis because they did not complete the treatment or did not return for follow up. Twenty-nine percent of the ears in the saline group and 33 % of the ears in the dexamethasone group showed significant improvement immediately after completion of treatment. Follow-up varied from 13 to 31 months, and the patients with improved tinnitus returned to the Proprietary Tinnitus Treatments Medical Clinical Policy Bulletins | Aetna Page 34 of 89 initial measurements over time. The authors concluded that there was no advantage in intra-tympanic injections of dexamethasone over saline solution in the treatment of severe, disabling tinnitus.

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The oral absorption of resve ratrol in humans is about 75%, although extensive metabolism in the intestine and liver results in an oral bioavailability considerably less than 1%. Major metabo lites include glucuronides and sulfates of resveratrol (Walle, 2011). Wine Chapter 26| 611 In the microbiota, red wine phenolic compounds are extensively metabo lized, especially by genera and species with enzymes necessary to catalyze these reactions (hydrolyzing and conjugating enzymes) (Rechner et al. Therefore, the colon is being considered as an active site for metabolism rather than a simple excre tion route and has been receiving much attention from the scientific com munity (Aura, 2008). This conversion may contribute to the absorption and modulation of the biological activity of red wine phenolics, which is different from the original compounds (Landete, 2012; Vendrame et al. In a human intervention study, modulation of the gut microbiota by using red wine was already described as an effective strategy for managing metabolic diseases associated with obesity (Moreno-Indias et al. An intervention study with red wine revealed significant changes in eight metabolites: 3,5-dihydroxybenzoic acid, 3-O-methylgallic acid, p-coumaric acid, phenylpropionic acid, protocatechuic acid, vanillic acid, syringic acid, and 4-hydroxy-5-(phenyl)valeric acid (Jimenez-Giron et al. It is important to highlight that O-methyl benzoic acids such as syringic and vanillic acids could arise from methoxyl ated anthocyanin catabolism (Aura et al. In addition, since anthocyanin phenolic acids can be further absorbed in colon, it is possible that these phenolic acids are additionally metabolized by hepatic cells (Woodward et al. Health benefits associated with red wine anthocyanin intake may also be explained by slow and continuous release of phenolic compounds through the gut into the bloodstream. Similar to what was reported for anthocyanins, proanthocyanidins can also be metabolized by microbial enzymes. Twenty-four dimeric metabolites with molecular weight greater than 290 were detected after procyanidin B2 was incu bated with human fecal microbiota (Stoupi et al. Microbiota may also cleave the interflavan bond to convert procyanidin B2 into two ()-epicatechin, after procyanidin B2 incubation with human fecal microbiota for up to 12h (Stoupi et al. The majority of proanthocyanidins reach the colon intact and are degraded into phenylvalerolactones and phenolic acids by colon micro biota (Appeldoorn et al. In vivo studies showed that microbial-derived phenylvalerolactone and phenolic acids were the predominant metabolites of procyanidins in blood and urine (Ottaviani et al. Urinary excretion of p-coumaric acid, vanillic acid, 3-hydroxybenzoic acid, and ferulic acid increased by over twofold in humans after consumption of 40 g of procyanidin rich cocoa powder (Urpi-Sarda et al. There was an increase in urinary excretion of microbial catabolites after human consumption of procyanidins and catechin monomers (Rios et al. Increasing evidence suggests that anthocyanins and proanthocyanidins have the potential to confer health benefits via modulation of the gut microbiota and by exerting pre biotic-like effects (Cueva et al. Pharmacokinetics and Metabolism of Resveratrol, Resveratrol in Health and Disease. Procyanidin dimers are metabolized by human microbiota with 2-(3,4-dihydroxyphenyl)acetic acid and 5-(3,4-dihydroxyphenyl)-gamma-valerolactone as the major metabolites. Changes in lipolysis and hormone-sensitive lipase expression caused by procyanidins in 3T3-L1 adipocytes. Interactions between favonoids and proteins: effect on the total antioxidant capacity. Anti oxidant features of red wine pyranoanthocyanins: experimental and theoretical approaches. Inhibition of amylase and glucoamylase by tannins extracted from cocoa, pomegranates, cranberries, and grapes. Current understanding of lifestyle and environmental factors and risk of non-hodgkin lymphoma: an epidemiological update. Inhibition of aggregation and secretion of human platelets by quercetin and other favonoids: structure-activity relationships. Amyloid beta-protein oligomerization: prenucleation interactions revealed by photo-induced cross-linking of unmodifed proteins. Bioavailability and biokinetics of anthocyanins from red grape juice and red wine. Hypolipidemic effects of proanthocyanidins and their underlying biochemical and molecular mechanisms. In vivo interactions between procyanidins and human saliva proteins: effect of repeated exposures to procyanidins solution. Kinetic and thermody namic study of proton transfer, hydration, and tautomeric reactions of malvidin 3-glucoside.

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Efficacy of a human anthrax vaccine in guinea pigs, rabbits, and rhesus ma caques against challenge by Bacillus anthracis isolates of diverse geographical origin. Humans or animals with plague pneumonia, endemic plague continues at low rates throughout the 4,5 particularly cats, can generate infectious aerosols. The resulting primary pneumonic plague is the most Deaths resulting from plague occur not because the severe and most frequently fatal form of the disease. Patients with the bubonic form of Y preventive medicine aspects of the disease will aid in pestis may develop secondary pneumonic plague, the prompt diagnosis and effective treatment necessary which can lead to human-to-human spread by the to survive a plague attack. However, it is possible that these in only a small number of animals, and to widespread patients were exposed by the oral/aerosol route and plague infections leading to death among susceptible developed pharyngeal plague that progressed into nest populations (ie, equivalent to an epidemic in a a systemic infection. The death of a rodent causes the which is more common in patients from developing living fleas to leave that host and seek other mammals, countries, may result from flea bites on the neck or including humans. Knowledge of these two concepts face while sleeping on the dirt floors of heavily flea helps to clarify how and when humans may be infected, infested buildings. Caffas large rat population helped spread the disease as they In the year of our Lord 1348 there occurred in the were carried on ships bound for major European ports city and contado of Florence a great pestilence, and such was its fury and violence that in whatever such as Pera, a suburb of Constantinople, and Messina, household it took hold, whosoever took care of in Sicily. However, thigh and the body, in the groin region, or under the some people believe that the plague persisted through armpit, there appeared a lump, and a sudden fever, 1720, with a final foray into Marseilles. During the 15th and when the victim spat, he spat blood mixed with through the 18th centuries, 30% to 60% of the popu saliva, and none of those who spat blood survived. The sick emitted a terrible stench: 11 Their sweat, excrement, spittle, breath, [were] so disease, rats seemed to escape attention. The pandemics decline was attributed land, persuaded the whole community to quarantine to the replacement of the black rat (Rattus rattus) in the itself when plague erupted there, but this was the worst area by the Norwegian rat (Rattus norvegicus), which possible solution because the people then remained is a less efficient host; natural vaccination of animals close to the infected rats. They grew to the size of 6 a small apple or an egg, more or less, and were vul satisfied Robert Kochs postulates for bubonic plague. In a short space of time these the reservoir of plague bacilli in the fleas of the Sibe tumours spread from the two parts named all over rian marmot was likely responsible for the Manchurian the body. The Texas Gulf Coast arrived in Bombay in 1898, and during the next 50 and Pensacola, Florida, also saw the influx of plague. Plague entered Vietnam in Nha Trang in 1898 and Endemic Disease several pneumonic epidemics have occurred since then. The reported tary operations in Egypt were significantly impeded by plague incidence increased from 8 cases in 1961 to 110 plague in 1798, which caused them to abandon their cases in 1963, and to an average of 4,500 cases annually 25,31-34 attack on Alexandria. The Genoese military installation include morbidity and mortality became infected with plague and fled to Italy. How of both humans and pets; loss of training and bivouac ever, the disease was most likely spread by the local sites; large expenditures of money, personnel, and population of infected rats, not by the corpses, because equipment to eliminate the plague risk; and the loss an infected flea leaves its host as soon as the corpse 25 11 of recreation areas. General Shiro and Muslim Tatars, the Tatar army was struck with Ishii, the physician leader of Unit 731, was fascinated plague. Two days later, bubonic plague occurred for the first this flea is resistant to air drag, naturally targets hu time in that city, resulting in 99 deaths in 34 days. No mans, and can infect a local rat population to prolong epizootic disease or increased mortality was found in an epidemic. However, clay bombs solved these technical difficulties and resulted in an In 1999 Dr Ken Alibek (Kanatjan Alibekov), a for 36 80% survival rate of fleas. The genus was named in honor of in nomenclature would increase the potential for Alexandre Yersin, the scientist who originally isolated laboratory-acquired plague infections. The isola is common in older colonies and is more pronounced tion of Y pestis pestoides from both Africa and Asia in certain strains. Y pestis Y pestis is a facultative anaerobe, fermenting glucose is nonmotile, unlike the other mammalian pathogens of with the production of acid. Although Y pestis grows well on separated into three biovars, based on the ability to 20 standard laboratory media such as sheep blood agar, reduce nitrate and ferment glycerol. Some molecular MacConkey agar, or heart infusion agar, growth is methods of typing, such as ribotyping and restriction slower than that of Y pseudotuberculosis or Y enteroco fragment-length polymorphisms of insertion sequence litica; more than 24 hours of incubation are required locations, support this division of strains. The round, moist, translucent, or demic, is the only biovar present in North and South opaque colonies are nonhemolytic on sheep blood agar America.